Challenges encountered by human immunodeficiency virus positive pregnant women on taking antiretrovirals in a public health unit of the Manzini region, Swaziland.

In Swaziland, the Ministry of Health adopted the prevention of mother-to-transmission (PMTCT) Option A as a feasible and less costly way to expand the PMTCT services nationwide. Despite major success since the programme started, some barriers, such as the challenge of follow-up care for human immunodeficiency virus (HIV)-positive pregnant mothers still exist. The present study aimed to describe the challenges that HIV-positive pregnant mothers encountered on taking antiretrovirals (ARVs) in a health unit of the Manzini region, Swaziland. A qualitative, exploratory and descriptive research design was used, and data were collected through semi-structured individual interviews and field notes. Purposive sampling was used to select the study site and the population. Permission was requested from the participants to record the interviews. The study population were HIV-positive pregnant mothers, aged between 18 and 40 years, which were enrolled in the PMTCT B+ programme. The PMTCT B+ programme was perceived as preventing the transfer of HIV transmission from mother to child. It boosts the mother's immune system, prevents opportunistic infections and prolongs life. Challenges of taking ARVs emerged as a theme. The participants displayed knowledge and understanding of the programme, yet discrimination and no support from families and partners were mentioned.

A randomized controlled trial evaluating the effects of a family-centered HIV care model on viral suppression and retention in care of HIV-positive children in Eswatini.

INTRODUCTION: A family-centered care model (FCCM) providing family-based HIV services, rather than separate adult/pediatric services, has been proposed to increase pediatric retention and treatment adherence. MATERIALS AND METHODS: Eight health-care facilities in the Hhohho region of Eswatini were randomized to implement FCCM (n = 4) or continue standard-of-care (SOC) separate adult/pediatric clinics (n = 4). HIV-positive children and caregivers were enrolled; caregiver interview and child/caregiver chart abstraction were done at enrollment and every three months; pediatric viral load was evaluated at enrollment and every six months through 12 months. Because of study group differences in 12-month viral load data availability (89.4% FCCM and 72.0% SOC children had 12-month viral load), we used three separate analyses to evaluate the effects of FCCM on children's viral suppression (<1,000 copies/mL) and undetectable virus (<400 copies/mL) at 12 months. In the first analysis, all children with missing viral outcome data were excluded from the analysis (modified intent to treat, mITT). The second analysis used inverse probability of missingness weighted logistic regression to estimate the effect of FCCM on 12-month viral outcomes compared to SOC (weighted mITT). For the third approach, missing virologic outcome data were imputed as virologic failure (imputed ITT). We also examined factors associated with viral suppression at 12 months using multivariable logistic regression. RESULTS: We enrolled 379 HIV-positive children and 363 caregivers. Among all children at enrollment, viral suppression and undetectability was 78.4% and 73.9%, respectively, improving to 90.2% and 87.3% at 12 months. In mITT and weighted mITT analyses, there was no significant difference in children's 12-month viral suppression between FCCM and SOC groups (89.2% and 91.6%, respectively). Using imputed ITT, there was a modest increase in 12-month viral suppression in FCCM versus SOC children (79.7% and 69.8%, respectively, p = 0.051) and 12-month undetectability (78.7% and 65.7%, respectively, p = 0.015). Among the 255 children suppressed at enrollment, more FCCM versus SOC children (98.0% versus 95.3%) were suppressed at 12-months, but this was not statistically significant in mITT or weighted mITT analyses, with a marginally significant difference using imputed mITT analysis (p = 0.042). A higher proportion of children suppressed at enrollment had undetectable viral load at 12 months in FCCM versus SOC children (98.0% versus 92.5%), a statistically significant difference across analytical methods. Among the 61 children unsuppressed at enrollment, achieving suppression was higher among SOC versus FCCM children, but this difference was not statistically significant and included only 38 children; and there were no significant differences in detectable viral load at 12 months. There were no significant differences between study groups in retention or ART adherence at 12 months for children or caregivers. Factors associated with lack of viral suppression/detectability at 12 months included lack of viral suppression at enrollment and having a younger caregiver (age <25 years). CONCLUSIONS: FCCM in Eswatini was associated with a modest increase in viral suppression/undetectability at 12-months; 12-month retention and adherence did not differ by study group for children or caregivers. High levels of suppression and retention in both groups may have limited our ability to detect a difference. TRIAL REGISTRATION: NCT03397420; ClinicalTrials.gov.

Prevalence of nonsuppressed viral load and associated factors among HIV-positive adults receiving antiretroviral therapy in Eswatini, Lesotho, Malawi, Zambia and Zimbabwe (2015 to 2017): results from population-based nationally representative surveys.

INTRODUCTION: The global target for 2020 is that ≥90% of people living with HIV (PLHIV) receiving antiretroviral therapy (ART) will achieve viral load suppression (VLS). We examined VLS and its determinants among adults receiving ART for at least four months. METHODS: We analysed data from the population-based HIV impact assessment (PHIA) surveys in Eswatini, Lesotho, Malawi, Zambia and Zimbabwe (2015 to 2017). PHIA surveys are nationally representative, cross-sectional household surveys. Data collection included structured interviews, home-based HIV testing and laboratory testing. Blood samples from PLHIV were analysed for HIV RNA, CD4 counts and recent exposure to antiretroviral drugs (ARVs). We calculated representative estimates for the prevalence of VLS (viral load <1000 copies/mL), nonsuppressed viral load (NVL; viral load ≥1000 copies/mL), virologic failure (VF; ARVs present and viral load ≥1000 copies/mL), interrupted ART (ARVs absent and viral load ≥1000 copies/mL) and rates of switching to second-line ART (protease inhibitors present) among PLHIV aged 15 to 59 years who participated in the PHIA surveys in Eswatini, Lesotho, Malawi, Zambia and Zimbabwe, initiated ART at least four months before the survey and were receiving ART at the time of the survey (according to self-report or ARV testing). We calculated odds ratios and incidence rate ratios for factors associated with NVL, VF, interrupted ART, and switching to second-line ART. RESULTS: We included 9200 adults receiving ART of whom 88.8% had VLS and 11.2% had NVL including 8.2% who experienced VF and 3.0% who interrupted ART. Younger age, male sex, less education, suboptimal adherence, receiving nevirapine, HIV non-disclosure, never having married and residing in Zimbabwe, Lesotho or Zambia were associated with higher odds of NVL. Among people with NVL, marriage, female sex, shorter ART duration, higher CD4 count and alcohol use were associated with lower odds for VF and higher odds for interrupted ART. Many people with VF (44.8%) had CD4 counts <200 cells/µL, but few (0.31% per year) switched to second-line ART. CONCLUSIONS: Countries are approaching global VLS targets for adults. Treatment support, in particular for younger adults, and people with higher CD4 counts, and switching of people to protease inhibitor- or integrase inhibitor-based regimens may further reduce NVL prevalence.

Predicting Sexually Transmitted Infections Among HIV+ Adolescents and Young Adults: A Novel Risk Score to Augment Syndromic Management in Eswatini.

BACKGROUND: Despite poor predictive power, syndromic screening is standard of care for diagnosing sexually transmitted infections (STIs) in low-resource, high HIV-burden settings. Predictive models may augment syndromic screening when diagnostic testing is not universally available for screening high-risk patient populations such as adolescents and young adults living with HIV. SETTING: Four hundred fifteen adolescents and young adults living with HIV, age 15-24 years, participated from 3 clinical sites in Eswatini, provided urine, sexual and medical history, and completed physical examination. METHODS: STI cases were defined by a positive Xpert result for Chlamydia trachomatis, Neisseria gonorrhea, or Trichomonas vaginalis. Features predictive of an STI were selected through Least Absolute Shrinkage and Selection Operator (LASSO) with 5-fold cross validation. Various model strategies were compared with parametric area under the Receiver Operator Curve (AUC) estimation and inferences were made with bootstrapped standard errors. RESULTS: Syndromic screening poorly predicted STIs [AUC 0.640 95% Confidence Interval (95% CI): 0.577 to 0.703]. A model considering 5 predictors (age group, sex, any sexual activity, not always using condoms (either self or partner), a partner who was 25 years or older, and horizontal or unknown mode of HIV acquisition) predicted STIs better than syndromic screening [AUC: 0.829 (95% CI: 0.774 to 0.885)] and was improved when the risk score was supplemented with leukocyte esterase (LE) testing [AUC: 0.883 (95% CI: 0.806 to 0.961)]. CONCLUSIONS: This simple predictive model, with or without leukocyte esterase testing, could improve STI diagnosis in HIV-positive adolescents and young adults in high burden settings through complementary use with syndromic screening and to guide patient selection for molecular STI diagnostic tests.

Expansion of HIV testing in Eswatini: stakeholder perspectives on reaching the first 90.

Achieving the United Nations' 90-90-90 goals has proven challenging in most settings and the ambitious 95-95-95 goals seem even more elusive. However, in Eswatini - a lower-middle-income country in sub-Saharan Africa with the highest HIV prevalence in the world - an estimated 92% of people living with HIV know their status. We conducted 26 in-depth interviews with stakeholders from policy, implementation, donor, local advocacy and academic sectors to elicit the facilitators and inhibitors to HIV testing uptake in Eswatini. Background data and related reports and policy documents (n = 57) were also reviewed. Essential facilitators included good governance via institutional and national budgetary commitments, which often led to swift adoption of globally recommended programs and standards. The integration of HIV testing into all points of care fostered a sense that testing was part of routine care, which reduced stigma. Challenges, however, centred on social norms that disadvantage certain groups with high ongoing HIV risk (such as key populations, adolescent girls and young women), a heavy reliance on external donor funding, and stigma that had subsided but nevertheless persisted. Amid concerns about whether the 90-90-90 targets could be achieved by 2020, the experience of Eswatini provides tangible insights into factors that have successfully influenced HIV testing uptake and may thus prove informative for other countries.

Early access to antiretroviral therapy versus standard of care among HIV-positive participants in Eswatini in the public health sector: the MaxART stepped-wedge randomized controlled trial.

INTRODUCTION: The WHO recommends antiretroviral treatment (ART) for all HIV-positive patients regardless of CD4 count or disease stage, referred to as "Early Access to ART for All" (EAAA). The health systems effects of EAAA implementation are unknown. This trial was implemented in a government-managed public health system with the aim to examine the "real world" impact of EAAA on care retention and viral suppression. METHODS: In this stepped-wedge randomized controlled trial, 14 public sector health facilities in Eswatini were paired and randomly assigned to stepwise transition from standard of care (SoC) to EAAA. ART-naïve participants ≥18 years who were not pregnant or breastfeeding were eligible for enrolment. We used Cox proportional hazard models with censoring at clinic transition to estimate the effects of EAAA on retention in care and retention and viral suppression combined. RESULTS: Between September 2014 and August 2017, 3405 participants were enrolled. In SoC and EAAA respectively, 12-month HIV care retention rates were 80% (95% CI: 77 to 83) and 86% (95% CI: 83 to 88). The 12-month combined retention and viral suppression endpoint rates were 44% (95% CI: 40 to 48) under SoC compared to 80% (95% CI: 77 to 83) under EAAA. EAAA increased both retention (HR: 1·60, 95% CI: 1·15 to 2·21, p = 0.005) and retention and viral suppression combined (HR: 4.88, 95% CI: 2.96 to 8.05, p < 0.001). We also identified significant gaps in current health systems ability to provide viral load (VL) monitoring with 80% participants in SoC and 66% in EAAA having a missing VL at last contact. CONCLUSIONS: The observed improvement in retention in care and on the combined retention and viral suppression provides an important co-benefit of EAAA to HIV-positive adults themselves, at least in the short term. Our results from this "real world" health systems trial strongly support EAAA for Eswatini and countries with similar HIV epidemics and health systems. VL monitoring needs to be scaled up for appropriate care management.

Modifiable risk factors associated with non-communicable diseases among adult outpatients in Manzini, Swaziland: a cross-sectional study.

BACKGROUND: Four major non-communicable diseases (NCD), including T2DM, contributed to nearly three-quarters of all deaths worldwide in 2017. Dietary and lifestyle actors associated with NCDs are potentially modifiable. Therefore, this study was conducted to determine the dietary and lifestyle factors associated with T2DM, pre-diabetes, and hypertension among adult outpatients in Manzini, Swaziland. METHODS: A random sample of 385 subjects aged 18 years and above was selected. The data regarding demographics, socio-economic status, lifestyle behaviour, diet, and physical activities were collected. Additionally, participants' anthropometric measurements and vital signs were taken. A biochemical examination was done for fasting plasma glucose, and a 2-h oral glucose tolerance test, where necessary. The Statistical Package for Social Sciences (SPSS) version 26 was used for this data analysis, and the level of statistical significance was set at p < 0.05. RESULTS: A total of 385 (197 men and 188 women) subjects aged 18 years and older participated in the study. The overall prevalence of hypertension was 48.3%, while the prevalence of hypertension stage 1 and 2 were 29.4 and 19%, respectively. Smoking, SES and consumption of sweet drinks, salty processed foods, fruits, and vegetables were significantly associated with T2DM. However, in the multivariate analysis, only consumption of vegetables (p < 0.0001), fruits (p =0.014), sweet drinks (p = 0.042), and salty processed foods (p = 0.005) remained significantly associated with T2DM. Smoking (p = 0.002) and consumption of fruits (p < 0.0001), vegetables (p < 0.0001), and sweet drinks (p = 0.043) were independently associated with pre-diabetes, while the consumption of vegetables (p = 0.002) and salty processed foods (p = 0.003) were the factors independently associated with hypertension. CONCLUSIONS: The factors associated with T2DM, pre-diabetes, and hypertension are potentially modifiable. Therefore, interventions which target lifestyle changes at primary health care and population levels are warranted to address the growing burden of these chronic conditions in Swaziland.

The social implications of participant choice on adherence to Isonaizid Preventive Therapy (IPT): A follow-up study to high completion rates in Eswatini.

BACKGROUND: Eswatini (formerly Swaziland) has one of the highest rates of TB and HIV co-disease in the world. Despite national efforts to improve service delivery and prevent TB and HIV transmission, rates remain high. A recent prospective, observational study of integrated, patient-selected IPT delivery showed extraordinary improvements in IPT adherence, running counter to previous assumptions. This prompted the need to understand contextual and unseen study factors that contributed to high rates of adherence. OBJECTIVE: To investigate high rates of IPT adherence rates among people living with HIV who participated in an observational study comparing modes of IPT delivery. METHODS: Community-based participatory research guided the development of in-person administration of semi-structured questionnaires. Observational and field note data were analyzed. Qualitative data were analyzed using content analysis. RESULTS: We interviewed 150 participants and analyzed responses from the 136 who remembered being given a choice of their IPT delivery method. Fifty-seven percent were female and the median age was 42. Nearly 67% of participants chose to receive facility-based IPT. High rates of self-reported IPT treatment adherence were linked to four key concepts: 1) adherence was positively impacted by community education; 2) disclosure of status served to empower participant completion; 3) mode of delivery perceptions positively impacted adherence; and 4) choice of treatment delivery seen as helpful but not essential for treatment completion. DISCUSSION: Achieving higher rates of IPT adherence in Eswatini and similar rural areas requires community-engaged education and outreach in coordination with care delivery systems.

Low rates of prior HIV testing among HIV-positive adults accessing outpatient services in Eswatini.

Prior HIV testing and awareness of HIV-positive status were assessed among HIV-positive adults at 20 clinics in Eswatini. Of 2196 HIV-positive adults, 1183 (53.8%) reported no prior HIV testing, and 1948 (88.7%) were unaware of their HIV-positive status. Males [adjusted odds ratio, AOR, (95% confidence interval): 0.7 (0.5-0.9)], youth 18-25 years [AOR 0.6 (0.4-0.95)], adults ≥ 50 years [AOR 0.5 (0.3-0.9)], those needing family support [AOR 0.6 (0.5-0.8)], and those living ≥ 45 min from clinic [AOR 0.5 (0.4-0.8)] were less likely to know their HIV-positive status. More HIV testing is needed to achieve 95-95-95 targets, with targeted strategies for those less likely to test for HIV.

Field Validation of Limiting-Antigen Avidity Enzyme Immunoassay to Estimate HIV-1 Incidence in Cross-Sectional Survey in Swaziland.

Reliable and accurate laboratory assays to detect recent HIV-1 infection have potential as simple and practical methods of estimating HIV-1 incidence in cross-sectional surveys. This study describes validation of the limiting-antigen (LAg) avidity enzyme immunoassay (EIA) in a cross-sectional national survey, conducted in Swaziland, comparing it to prospective follow-up incidence. As part of the Swaziland HIV-1 Incidence Measurement Survey (SHIMS), 18,172 individuals underwent counseling and HIV rapid testing in a household-based, population survey conducted from December 2010 to June 2011. Plasma samples from HIV-positive persons were classified as recent infections using an incidence testing algorithm with LAg-Avidity EIA (normalized optical density ≤1.5) followed by viral load (VL ≥1,000 copies/mL). All HIV-seronegative samples were tested for acute HIV-1 infection by nucleic acid amplification test (NAAT) pooling. HIV-seronegative individuals who consented to follow-up were retested ∼6 months later to detect observed HIV-1 seroconversion. HIV-1 incidence estimates based on LAg+VL and NAAT were calculated using assay-specific parameters and were compared with prospective incidence estimate. A total of 5,803 (31.9%) of 18,172 survey participants tested HIV seropositive; of these 5,683 (97.9%) were further tested with LAg+VL algorithm. The weighted annualized incidence from the longitudinal cohort study was 2.4% (95% confidence interval 2.0-2.7). Based on cross-sectional testing of HIV positives with LAg+VL algorithm, overall weighted annualized HIV-1 incidence was 2.5% (2.0-3.0), whereas NAAT-based incidence was of 2.6%. In addition, LAg-based incidence in men (1.8%; 1.2-2.5) and women (3.2%; 2.4-3.9) were similar to estimates based on observed incidence (men = 1.7%, women = 3.1%). Changes in HIV-1 incidence with age in men and women further validate plausibility of the algorithm. These results demonstrate that the LAg EIA, in a serial algorithm with VL, is a cost-effective tool to estimate HIV-1 incidence in cross-sectional surveys.

"I don't want them to know": how stigma creates dilemmas for engagement with Treat-all HIV care for people living with HIV in Eswatini.

"Treat-all" programmes aim to improve clinical outcomes and to reduce HIV transmission through regular HIV testing and immediate offer of antiretroviral therapy (ART) for those diagnosed HIV-positive, irrespective of immunological status and symptoms of disease. Global narratives on the benefits of Treat-all anticipate reduced HIV-related stigma and increased "normalisation" of HIV with Treat-all implementation, whereby HIV is remoulded as a manageable, chronic condition where stigmatising symptoms can be concealed. Drawing on Goffman's stigma work, we aimed to investigate how stigma may influence the engagement of clinically asymptomatic people living with HIV (PLHIV) with Treat-all HIV care in Shiselweni, Eswatini (formerly Swaziland). This longitudinal research comprised 106 interviews conducted from August 2016 to September 2017, including repeated interviews with 30 PLHIV, and one-off interviews with 20 healthcare workers. Data were analysed thematically using NVivo 11, drawing upon principles of grounded theory to generate findings inductively from participants' accounts. Stigma was pervasive within the narratives of PLHIV, framing their engagement with treatment and care. Many asymptomatic PLHIV were motivated to initiate ART in order to maintain a "discreditable" status, by preventing the development of visible and exposing symptoms. However, engagement with treatment and care services could itself be exposing. PLHIV described the ways in which these "invisibilising" benefits and exposing risks of ART were continually assessed and navigated over time. Where the risk of exposure was deemed too great, this could lead to intermittent treatment-taking, and disengagement from care. Addressing HIV related stigma is crucial to the success of Treat-all, and should thus be a core component of HIV responses.

'Then her neighbour will not know her status': how health providers advocate antiretroviral therapy under universal test and treat.

Introduction: Universal test and treat (UTT)-antiretroviral therapy (ART) for all HIV-positive individuals regardless of CD4 count-is the WHO's recommended treatment guideline. UTT has implications for health providers' workload in areas of high HIV prevalence and for understandings of ART and HIV. This article explores health providers' experiences of implementing UTT in Hhohho Region, Eswatini. Methods: Between March 2015 and October 2016, in-depth interviews were conducted with health providers implementing UTT. Interviews were transcribed verbatim and translated into English for qualitative content analysis. Results: Twenty-five providers from eight facilities were interviewed. Respondents encouraged early ART by promoting its overall health benefits, and the possibility of avoiding disclosure and HIV-related stigma in the community. Some health providers downplayed UTT's preventive benefits to avoid discouraging condom use. Respondents suggested that initiating ART immediately after testing could improve linkage-to-care, but recognized that overly hasty initiation might affect adherence. Viral load testing was seen as a potentially useful tool to monitor clients' response to ART. Conclusions: Health providers appropriated stigma to encourage early ART. This suggests an attentiveness to the social burden of HIV/AIDS, but potentially exacerbates discrimination and conflicts with efforts to reduce HIV-related stigma.

Distribution of cervical abnormalities detected by visual inspection with acetic acid in Swaziland, 2011-2014: A retrospective study.

BACKGROUND:  Cervical cancer is the fourth most common cancer worldwide among women, with the number of new cases increasing from 493 243 in 2002 to 527 000 in 2012. These numbers are likely to be underestimated because given the lack of registration resources, cervical cancer deaths are usually under-reported in low-income countries. AIM:  To describe the distribution of and trends in visual inspection with acetic acid (VIA) to detected cervical abnormalities in Swaziland by reviewing records of VIA examinations performed at two main hospitals in Swaziland between 2011 and 2014. SETTING:  Mbabane Government Hospital and Realign Fitkin Memorial (RFM). METHODS:  Records of cervical screening using VIA at the Mbabane government hospital and RFM hospital between 2011 and 2014 were retrieved. Positivity rates (PRs) of VIA with 95% confidence intervals (95% CI) were calculated and used as proxies of cervical abnormalities. Odds ratios of the association between VIA-detected cervical abnormalities and human immunodeficiency virus (HIV) status were estimated using logistic regressions. RESULTS:  VIA was positive in 1828 of 12 151 VIA records used for analysis (15%, 95% CI: 14.4-15.7). VIA was positive in 9% (36 of 403) women under the age of 20, in 15.5% (1714 of 11 046) of women aged 20-49 years and in 11.1% (78 of 624) of women aged 50-64 years. A decreasing trend of VIA positivity was observed over time at both screening centres (p for trend < 0.001). Of 2697 records with Papanicolaou results, 20% (67 of 331) VIA-positives and only 5% (114 of 2366) VIA negatives had high-grade squamous intraepithelial lesion. Among 4578 women with reported HIV status, 1702 were HIV-positive (37.2%, 95% CI: 35.8-38.6). The prevalence of HIV in VIA-positive women was 62.5% (95% CI: 58.7-66.2), almost double that among VIA-negative women (33.0%, 95% CI: 31.6-34.5) and that among all women screened (p < 0.001). HIV-positive women were 3.4 times more likely to have cervical abnormalities on VIA than HIV-negative women (OR: 3.4, 95% CI: 2.8-4.0, p < 0.01). CONCLUSION:  The high VIA PRs observed over four years in this study may reflect the prevalence of cervical abnormalities, in particular, in HIV-positive women. VIA is not a robust screening test, but it can play a major role in strengthening and expanding cervical cancer screening prevention programmes in resource-limited countries.

Cost-effectiveness of a combination strategy to enhance the HIV care continuum in Swaziland: Link4Health.

INTRODUCTION: Link4Health, a cluster-RCT, demonstrated the effectiveness of a combination strategy targeting barriers at various HIV continuum steps on linkage to and retention in care; showing effectiveness in achieving linkage to HIV care within 1 month plus retention in care at 12 months after HIV testing for people living with HIV (RR 1.48, 95% CI 1.19-1.96, p = 0.002). In addition to standard of care, Link4Health included: 1) Point-of-care CD4+ count testing; 2) Accelerated ART initiation; 3) Mobile phone appointment reminders; 4) Care and prevention package including commodities and informational materials; and 5) Non-cash financial incentive. Our objective was to evaluate the cost-effectiveness of a scale-up of the Link4Health strategy in Swaziland. METHODS AND FINDINGS: We incorporated the effects and costs of the Link4Health strategy into a computer simulation of the HIV epidemic in Swaziland, comparing a scenario where the strategy was scaled up to a scenario with no implementation. The simulation combined a deterministic compartmental model of HIV transmission with a stochastic microsimulation of HIV progression calibrated to Swaziland epidemiological data. It incorporated downstream health costs potentially saved and infections potentially prevented by improved linkage and treatment adherence. We assessed the incremental cost-effectiveness ratio of Link4Health compared to standard care from a health sector perspective reported in US$2015, a time horizon of 20 years, and a discount rate of 3% in accordance with WHO guidelines.[1] Our results suggest that scale-up of the Link4Health strategy would reduce new HIV infections over 20 years by 11,059 infections, a 7% reduction from the projected 169,019 cases and prevent 5,313 deaths, an 11% reduction from the projected 49,582 deaths. Link4Health resulted in an incremental cost per infection prevented of $13,310 and an incremental cost per QALY gained of $3,560/QALY from the health sector perspective. CONCLUSIONS: Using a threshold of <3 x per capita GDP, the Link4Health strategy is likely to be a cost-effective strategy for responding to the HIV epidemic in Swaziland.

Marginalization and social change processes among lesbian, gay, bisexual and transgender persons in Swaziland: implications for HIV prevention.

Swaziland has among the highest national adult HIV prevalence globally. There is limited knowledge of HIV vulnerabilities and prevention engagement among lesbian, gay, bisexual and transgender (LGBT) persons in the context of Swaziland's criminalization of consensual same-sex practices. This study explored social processes of marginalization to assess how they could potentiate HIV vulnerabilities and limit engagement in HIV prevention services. Additionally, we assessed positive change to better understand existing strategies employed by LGBT persons to challenge these HIV prevention barriers. Guided by community-based research methodology and conducted in Mbabane and Manzini, Swaziland, data were collected by LGBT peer-research assistants (PRA) in collaboration with an LGBT community organization in Manzini. Semi-structured interviews were conducted by trained PRAs and explored HIV prevention, including experiences of stigma and coping. Audio files were transcribed verbatim, translated to English, and analyzed using thematic techniques. Among participants (n = 51; mean age: 26.47, SD: 4.68), 40 self-identifed as gay or lesbian (78.4%), 11 bisexual (22.6%), and 12 (23.5%) identified as transgender. Findings highlighted three primary processes of marginalization and positive change in structural, community, and internal domains. First, structural marginalization, which included criminalization, healthcare discrimination, and a scarcity of LGBT tailored HIV prevention resources was challenged by grassroots networks created to access and share specific HIV resources with LGBT persons and the Ministry of Health. Second, community marginalization included stigma and multi-dimensional forms of violence, however, this was met with LGBT persons providing mutual peer support, including for accessing HIV testing services. Thirdly, internal marginalization comprised of self-stigma and associated sexual risk practices was contrasted with coping strategies focused on self-acceptance, stemming from social support and leading to healthcare utilization. Jointly, these findings can inform the implementation of community-based and rights affirming HIV prevention and care cascade strategies that improve coverage of services with LGBT persons in Swaziland.

Projected cervical Cancer incidence in Swaziland using three methods and local survey estimates.

BACKGROUND: The scarcity of country data (e.g. a cancer registry) for the burden of cervical cancer (CC) in low-income countries (LCIs) such as Swaziland remains a huge challenge. Such data are critical to inform local decision-making regarding resource allocation [1]. We aimed to estimate likely cervical cancer incidence in Swaziland using three different methodologies (triangulation), to help better inform local policy guidance regarding likely higher "true" burden and increased resource allocation required for treatment, cervical cancer screening and HPV vaccine implementation. METHODS: Three methods were applied to estimate CC incidence, namely: 1) application of age-specific CC incidence rates for Southern African region from GLOBOCAN 2012 extrapolated to the 2014 Swaziland female population; 2) a linear regression based model with transformed age-standardised CC incidence against hr-HPV (with and without HIV as a covariate) prevalence among women with normal cervical cytology; and 3) a mathematical model, using a natural history approach based on parameter estimates from various available literature and local survey estimates. We then triangulated estimates and uncertainty from the three models to estimate the most likely CC incidence rate for Swaziland in 2015. RESULTS: The projected incidence estimates for models 1-3 were 69.4 (95% CI: 66.7-72.1), 62.6 per 100,000 (95%CI: 53.7-71.8) and 44.6 per 100,000 (41.5 to 52.1) respectively. Model 2 with HIV prevalence as covariate estimated a higher CC incidence rate estimate of 101.1 per 100,000 (95%CI: 90.3-112.2). The triangulated ('averaged') age-standardized CC incidence based across the 3 models for 2015 was estimated at 69.4 per 100,000 (95% CI: 63.0-77.1) in Swaziland. CONCLUSION: It is widely accepted that cancer incidence (and in this case CC) is underestimated in settings with poor and lacking registry data. Our findings suggest that the projected burden of CC is higher than that suggested from other sources. Local health policy decisions and decision-makers need to re-assess resource allocation to prevent and treat CC effectively, which is likely to persist given the very high burden of hr-HPV within the country.

Early impact of rotavirus vaccine in under 5year old children hospitalized due to diarrhea, Swaziland.

BACKGROUND: Swaziland introduced rotavirus vaccine in the National Immunization Program, in May 2015, with the objective of reducing the burden of rotavirus diarrheal disease. We monitored the early impact of the vaccine in reducing rotavirus diarrhea. METHODS: We conducted sentinel rotavirus surveillance from January 2013 to December 2016 in children under five years of age admitted due to diarrhea attending Mbabane Government Referral Hospital in the Hhohho Region and Raleigh Fitkin Memorial Hospital in the Manzini Region. All cases had stool samples collected and tested for rotavirus antigen by enzyme immunoassay. RESULTS: Between 2013 and 2016, 596 samples were collected and tested. Rotavirus positivity reduced from average of 50.8% (172/338) (in 2013-2014 (pre vaccine period)) to 29% (24/82) in 2016, post-vaccine introduction. The median age of children with rotavirus infection increased from average of 10months in 2013-2014 to 13.7months in 2016. The peak season for all-cause diarrhea and rotavirus-specific hospitalizations among children under five years of age was June-August in all years with a blunting of the peak season in 2016. Rotavirus positivity among children 0-11months reduced from an average of 49% in 2013-2014 (116/236) to 33% (15/45) in 2016, a 33% reduction following rotavirus vaccine introduction. CONCLUSION: There has been a rapid reduction of all-cause diarrhea and rotavirus hospitalizations in Swaziland, particularly in young children and during the rotavirus season, after the introduction rotavirus vaccine. Continued surveillance is needed to monitor the long-term impact of rotavirus vaccine introduction.

An analysis of human exposure to trace elements from deliberate soil ingestion and associated health risks.

Fifty-seven samples of soils commonly ingested in South Africa, Swaziland, Democratic Republic of Congo (DRC), and Togo were analyzed for the concentrations of arsenic (As), cadmium (Cd), cobalt (Co), chromium (Cr), copper (Cu), lead (Pb), manganese (Mn), nickel (Ni), and zinc (Zn) and their bioaccessibility in the human gastrointestinal tract. Bioaccessibility values were used to calculate daily intake, and hazard quotient of each trace element, and chronic hazard index (CHI) of each sample. Carcinogenic risk associated with As and Ni exposure were also calculated. Mean pseudo-total concentrations of trace elements in all samples were 7.2, 83.3, 77.1, 15.4, 28.6, 24.9, 56.1, 2.8, and 26.5 mg/kg for As, Cr, Mn, Co, Ni, Cu, Zn, Cd, and Pb, respectively. Percent bioaccessibility of Pb (13-49%) and Zn (38-56%) were highest among trace elements studied. Average daily intake values were lower than their respective reference doses for ell elements except for Pb in selected samples. Samples from DRC presented the highest health risks associated with trace element exposure with most of the samples having CHI values between 0.5 and 1.0. Some samples had higher than unacceptable values of carcinogenic risk associated with As and Ni exposure. Results indicate low trace element exposure risk from ingesting most of the soil samples.

'Worse than HIV': The logics of cancer screening avoidance in Swaziland.

This article shows the consequences of competing global health agendas within differential clinical and social worlds. Specifically, it examines how HIV's prominence in local clinical programming in Swaziland influences cervical cancer screening rates. Drawing on 2014 ethnographic research conducted in a semi-urban town in Swaziland, the interview and participant observation data show the relative scarcity of cervical cancer care and the consequences of HIV/AIDS funding and programming dominance. 20 women and 7 health workers were interviewed in homes, clinics and small businesses. Data were analysed using frameworks of medicoscapes and therapeutic citizenship. Results show that women's patterns of screening avoidance were based on lengthy diagnostic procedures, treatment expense, therapeutic travel to neighbouring South Africa, and frequent therapeutic failure. In sum, avoidance of cervical screening in Swaziland has structural components, and is a product of organisational and political choices at local and global levels. This study challenges culturalist assumptions about African women's avoidance of cervical cancer screening. In the future, delivering successful cervical cancer screening in Swaziland will depend on expanding cancer screening and treatment, which should be informed by perceptions of clinical care held by the very women public health practitioners aim to keep healthy.

High completion rates of isoniazid preventive therapy among persons living with HIV in Swaziland.

SETTING: Five human immunodeficiency virus (HIV) care facilities in Swaziland. OBJECTIVE: To assess adherence and treatment completion of a 6-month course of isoniazid preventive therapy (IPT) provided to HIV-infected patients through a self-selected model of facility-based, community-based or peer-supported IPT delivery coordinated with antiretroviral refills. DESIGN: Prospective cohort study. RESULTS: Between February and August 2015, we enrolled 908 patients, with follow-up until February 2016. Most were female (66.2%), with a median age of 38 years (interquartile range 31-45). Most (n = 797, 87.8%) chose facility-based delivery, 111 (12.2%) selected community-based delivery, and none selected peer-supported delivery. Adherence was high in both cohorts; among those with available data, 794 (94.8%) reported taking at least 80% of their IPT (P > 0.05). Twenty-two patients screened positive for tuberculosis (TB) at any visit; all had TB excluded and most continued IPT. In total, 812 (89.4%) patients completed treatment: 711 (89.2%) were on facility-based and 111 (91.0%) on community-based IPT (P > 0.05). No confirmed treatment failures occurred. Few patients discontinued IPT (6.3%) or were lost to follow-up (4.1%). CONCLUSION: Self-selected IPT delivery aligned with HIV care achieved high rates of adherence and treatment completion. This model may improve outcomes by simplifying clinic visits and conferring agency to the patient, and may be readily implemented in similar high TB-HIV burden settings.