Malaria elimination and the need for intensive inter-country cooperation. a critical evaluation of regional technical co-operation in Southern Africa.

BACKGROUND: Malaria elimination requires closely co-ordinated action between neighbouring countries. In Southern Africa several countries have reduced malaria to low levels, but the goal of elimination has eluded them thus far. The Southern Africa Development Community (SADC) Malaria Elimination Eight (E8) initiative was established in 2009 between Angola, Botswana, Eswatini, Mozambique, Namibia, South Africa, Zambia, and Zimbabwe to coordinate malaria interventions aiming to eliminate malaria by 2030. Cross-border coordination is important in malaria elimination settings as it strengthens surveillance, joint planning and implementation, knowledge exchange and optimal use of resources. This paper describes how this collaboration is realized in practice, its achievements and challenges, and its significance for malaria elimination prospects. METHODS: The ministers of health of the E8 countries oversee an intergovernmental technical committee supported by specialist working groups consisting of technical personnel from member countries and partner institutions. These technical working groups are responsible for malaria elimination initiatives in key focus areas such as surveillance, vector control, diagnosis, case management, behaviour change and applied research. The technical working groups have initiated and guided several collaborative projects which lay essential groundwork for malaria elimination. RESULTS: The E8 collaboration has yielded achievements in the following key areas. (1) Establishment and evaluation of malaria border health posts to improve malaria services in border areas and reduce malaria among resident and, mobile and migrant populations. (2) The development of a regional malaria microscopy slide bank providing materials for diagnostic training and proficiency testing. (3) A facility for regional external competency assessment and training of malaria microscopy trainers in collaboration with the World Health Organization. (4) Entomology fellowships that improved capacity in entomological surveillance; an indoor residual spraying (IRS) training of trainers' scheme to enhance the quality of this core intervention in the region. (5) Capacity development for regional malaria parasite genomic surveillance. (6) A mechanism for early detection of malaria outbreak through near real time reporting and a quarterly bulletins of malaria incidence in border districts. CONCLUSIONS: The E8 technical working groups system embodies inter-country collaboration of malaria control and elimination activities. It facilitates sustained interaction between countries through a regional approach. The groundwork for elimination has been laid, but the challenge will be to maintain funding for collaboration at this level whilst reducing reliance on international donors and to build capacities necessary to prepare for malaria elimination.

"It is still very little; I cannot pass it on": a qualitative study of experiences of diagnosis and treatment of acute HIV infection in Eswatini.

Acute and early HIV infection (AEHI) is rarely diagnosed in sub-Saharan Africa, despite its potential contribution to incidence reduction. This qualitative study in Eswatini explored the experiences of health workers, people diagnosed with AEHI, and their partners towards AEHI diagnosis, to inform its scale-up. In-depth interviews were undertaken with 11 women and four men diagnosed with AEHI. Three patients' partners were interviewed about their understanding of AEHI and six health workers were interviewed about experiences of delivering AEHI services. Data were coded inductively and analysed iteratively following the principles of grounded theory. Experiences with AEHI diagnoses were shaped by (i) understanding the nature and consequences of AEHI, and (ii) social norms that influence disclosure and sexual behaviour. AEHI was a new concept for health workers who struggled to explain it to patients, leading to some confusion over their HIV status and misunderstandings around its high transmissibility and prognosis. Disclosure tended to occur to primary partners, if at all, limiting the ability to provide partner services, and one relationship breakdown was reported. If AEHI diagnosis and care interventions are to realise their full potential, it will be essential to reinforce the accompanying counselling sessions and closely monitor for potential social harms.

Associations between forced non-consensual first-sex and HIV among sexually active women in the Kingdom of Eswatini.

Studies continue to underscore the profound impact of sexual violence on women's health. Yet, little is known about the impact, via a complex matrix of behavioural and social factors, of first intercourse, namely forced non-consensual on HIV status, particularly among sexually active women (SAW) in low-income countries where HIV prevalence remains high. Using a national sample from Eswatini, we employed multivariate logistic regression modelling to estimate the associations between forced first-sex (FFS), subsequent sexual behaviour and HIV status among 3555 SAW aged from 15 years to 49 years. The results found that women who experienced FFS had a greater number of sexual partners compared to those who had never experienced FFS (aOR = 2.79, p < .01), although there were no significant differences in condom use, early sexual debut and casual sex involvement between these two groups. FFS remained significantly associated with a higher risk of having HIV (aOR = 1.70, p < .05) even after controlling for risky sexual behaviours and various other factors. These findings further reinforce the relationship between FFS and HIV, and suggest that addressing sexual violence is a critical component of HIV prevention among women in low-income countries.

Understanding the role of video direct observed therapy for patients on an oral short-course regimen for multi-drug resistant tuberculosis: findings from a qualitative study in Eswatini.

BACKGROUND: Improving treatment success rates among multi drug-resistant tuberculosis (MDR-TB) patients is critical to reducing its incidence and mortality, but adherence poses an important challenge. Video-based direct observed therapy (vDOT) may provide adherence benefits, while addressing the time and cost burden associated with community treatment supporter (CTS)-DOT. This study explored experiences of patients, family members and healthcare workers with different DOT modalities for adherence support in Eswatini. METHODS: Between April 2021 and May 2022, thirteen men and five women with MDR-TB, ten healthcare workers, and nine caregivers were purposively sampled to include a range of characteristics and experiences with DOT modalities. Data were generated through individual in-depth interviews and a smartphone messaging application (WhatsApp). Data coding was undertaken iteratively, and thematic analysis undertaken, supported by Nvivo. RESULTS: Four themes emerged that reflected participants' experiences with different DOT modalities, including stigma, efficiency, perceived risks of TB acquisition, and patient autonomy. vDOT was appreciated by patients for providing them with privacy and shielding them from stigmatisation associated with being seen in TB clinics or with community treatment supporters. vDOT was also seen as more efficient than CTS-DOT. Health workers acknowledged that it saved time, allowing them to attend to more patients, while many patients found vDOT more convenient and less expensive by removing the need to travel for in-person consultations. Health workers also appreciated vDOT because it reduced risks of TB acquisition by minimising exposure through virtual patient monitoring. Although many patients appreciated greater autonomy in managing their illness through vDOT, others preferred human contact or struggled with making video recordings. Most family members appreciated vDOT, although some resented feeling removed from the process of supporting loved ones. CONCLUSIONS: vDOT was generally appreciated by MDR-TB patients, their family members and health workers as it addressed barriers to adherence which could contribute to improved treatment completion rates and reduced workplace exposure. However, patients should be offered an alternative to vDOT such as CTS-DOT if this modality does not suit their circumstances or preferences.

Costs of distributing HIV self-testing kits in Eswatini through community and workplace models.

BACKGROUND: This study evaluates the implementation and running costs of an HIV self-testing (HIVST) distribution program in Eswatini. HIVST kits were delivered through community-based and workplace models using primary and secondary distribution. Primary clients could self-test onsite or offsite. This study presents total running economic costs of kit distribution per model between April 2019 and March 2020, and estimates average cost per HIVST kit distributed, per client self-tested, per client self-tested reactive, per client confirmed positive, and per client initiating antiretroviral therapy (ART). METHODS: Distribution data and follow-up phone interviews were analysed to estimate implementation outcomes. Results were presented for each step of the care cascade using best-case and worst-case scenarios. A top-down incremental cost-analysis was conducted from the provider perspective using project expenditures. Sensitivity and scenario analyses explored effects of economic and epidemiological parameters on average costs. RESULTS: Nineteen thousand one hundred fifty-five HIVST kits were distributed to 13,031 individuals over a 12-month period, averaging 1.5 kits per recipient. 83% and 17% of kits were distributed via the community and workplace models, respectively. Clients reached via the workplace model were less likely to opt for onsite testing than clients in the community model (8% vs 29%). 6% of onsite workplace testers tested reactive compared to 2% of onsite community testers. Best-case scenario estimated 17,458 (91%) clients self-tested, 633 (4%) received reactive-test results, 606 (96%) linked to confirmatory testing, and 505 (83%) initiated ART. Personnel and HIVST kits represented 60% and 32% of total costs, respectively. Average costs were: per kit distributed US$17.23, per client tested US$18.91, per client with a reactive test US$521.54, per client confirmed positive US$550.83, and per client initiating ART US$708.60. Lower rates for testing, reactivity, and linkage to care in the worst-case scenario resulted in higher average costs along the treatment cascade. CONCLUSION: This study fills a significant evidence gap regarding costs of HIVST provision along the client care cascade in Eswatini. Workplace and community-based distribution of HIVST accompanied with effective linkage to care strategies can support countries to reach cascade objectives.

Human and financial resource needs for universal access to WHO-PEN interventions for diabetes and hypertension care in Eswatini: results from a time-and-motion and bottom-up costing study.

BACKGROUND: Eswatini faces persistent challenges in providing care for diabetes and hypertension, exacerbated by a shortage of healthcare workers. The implementation of WHO-PEN interventions aimed to address these issues, yet their effects on healthcare worker time requirements and associated costs remain unclear. METHODS: This study employed a time-and-motion analysis and a bottom-up cost assessment to quantify the human and financial resources required for scaling up WHO-PEN interventions nationally in Eswatini for all estimated diabetic and hypertensive patients. RESULTS: Findings reveal that healthcare workers in intervention-arm clinics reported longer workday durations compared to those in control-arm clinics, yet spent less time per patient while seeing more patients. The implementation of WHO-PEN interventions increased the workload on healthcare workers but also led to a notable increase in patient care utilization. Furthermore, a morning peak in patient visits was identified, suggesting potential opportunities for optimizing patient flow. Notably, scaling up care provision nationally with WHO-PEN interventions proved to be more cost saving than expanding standard-of-care treatment. CONCLUSION: WHO-PEN interventions hold promise in improving access to diabetes and hypertension care in Eswatini while offering an efficient solution. However, addressing challenges in healthcare workforce creation and retention is crucial for sustained effectiveness. Policy makers must consider all aspects of the WHO-PEN intervention for informed decision-making. Trial registration US Clinical Trials Registry. NCT04183413. Trial registration date: December 3, 2019. https://ichgcp.net/clinical-trials-registry/NCT04183413.

Sociodemographic factors underlying lifetime fertility among ever-married Swazi women.

Fertility rates remain high in certain subgroups of the population, and there is limited research about the sociodemographic factors influencing fertility, particularly in Eswatini where women are often considered minors. This study aims to investigate the changes in lifetime fertility, and the associations between sociodemographic factors and lifetime fertility among ever-married women. The study used secondary cross-sectional data from the 2010 and 2014 Eswatini Multiple Indicator Cluster Surveys (MICS), with a sample size of 2,295 and 2,351 women, respectively. The data was analysed using descriptive statistics and multivariable Poisson regression. The results showed that fertility rates decreased from 3.47 to 3.21 children between 2010 and 2014. The study found that child loss and age (25+ years) were significant factors associated with higher fertility, while delayed age at marriage and sexual debut (20+ years), at least secondary education, and being rich were strong predictors of lower fertility rates. The study recommends creating awareness about and strengthening laws to abolish early sexual debut and marriage. It also suggests empowering women through education, encouraging the use of contraceptives, and providing maternal and child health services in rural areas where fertility rates tend to be higher.

Les taux de fécondité restent élevés dans certains sous-groupes de la population, et les recherches sur les facteurs sociodémographiques influençant la fécondité sont limitées, en particulier à Eswatini où les femmes sont souvent considérées comme mineures. Cette étude vise à étudier les changements dans la fécondité au cours de la vie et les associations entre les facteurs sociodémographiques et la fécondité au cours de la vie chez les femmes déjà mariées. L'étude a utilisé des données transversales secondaires des enquêtes par grappes à indicateurs multiples (MICS) d'Eswatini de 2010 et 2014, avec un échantillon de 2 295 et 2 351 femmes, respectivement. Les données ont été analysées à l'aide de statistiques descriptives et d'une régression de Poisson multivariée. Les résultats ont montré que les taux de fécondité ont diminué de 3,47 à 3,21 enfants entre 2010 et 2014. L'étude a révélé que la perte d'enfants et l'âge (25 ans et plus) étaient des facteurs importants associés à une fécondité plus élevée, tandis qu'un âge plus tardif au mariage et aux débuts sexuels (20 ans et plus) ), au moins une éducation secondaire, et le fait d'être riche étaient de puissants prédicteurs de taux de fécondité plus faibles. L'étude recommande de sensibiliser et de renforcer les lois visant à abolir les premiers rapports sexuels et le mariage précoces. Il suggère également d'autonomiser les femmes grâce à l'éducation, d'encourager l'utilisation de contraceptifs et de fournir des services de santé maternelle et infantile dans les zones rurales où les taux de fécondité ont tendance à être plus élevés.

Risk Factors for Recent HIV Infections among Adults in 14 Countries in Africa Identified by Population-Based HIV Impact Assessment Surveys, 2015-2019.

Identifying persons who have newly acquired HIV infections is critical for characterizing the HIV epidemic direction. We analyzed pooled data from nationally representative Population-Based HIV Impact Assessment surveys conducted across 14 countries in Africa for recent infection risk factors. We included adults 15-49 years of age who had sex during the previous year and used a recent infection testing algorithm to distinguish recent from long-term infections. We collected risk factor information via participant interviews and assessed correlates of recent infection using multinomial logistic regression, incorporating each survey's complex sampling design. Compared with HIV-negative persons, persons with higher odds of recent HIV infection were women, were divorced/separated/widowed, had multiple recent sex partners, had a recent HIV-positive sex partner or one with unknown status, and lived in communities with higher HIV viremia prevalence. Prevention programs focusing on persons at higher risk for HIV and their sexual partners will contribute to reducing HIV incidence.

Out-of-pocket Expenses and Time Spent on Clinic Visits Among HIV Pre-exposure Prophylaxis Users and Other Clinic Attendees in Eswatini.

User costs constitute a barrier to the uptake of HIV pre-exposure prophylaxis (PrEP), but their magnitude appears rarely assessed. In this prospective observational study, we assessed self-reported out-of-pocket expenses (OOPE) and time spent on clinic visits during a PrEP demonstration project in Eswatini. At six public primary care clinics, 240 PrEP users and other clinic attendees were interviewed after a clinic visit. Among the 79.2% of clinic attendees reporting any medical OOPE (e.g., expenses for consultations or drugs) and/or non-medical OOPE (e.g., expenses for transport, food, or phone use), the median total OOPE was $1.36 (IQR 0.91-1.96). Non-medical OOPE occurred mostly due to transport expenses. The median travel time for a clinic visit was 1.0 h (IQR 0.67-2.0). The median time spent in the clinic was 2.0 h (IQR 1.15-3.0). The median opportunity cost of a clinic visit was $7.54 (IQR 5.42-11) when valuing time spent on a clinic visit with Eswatini's per-capita gross domestic product. Our findings can guide measures to reduce the user costs of PrEP in Eswatini and other contexts in which oral PrEP is provided through health care facilities.

RESUMEN: Los costes de los usuarios constituyen un obstáculo para la adopción de la profilaxis previa a la exposición al VIH (PrEP), pero su magnitud rara vez se evalúa. En este estudio observacional prospectivo, evaluamos los gastos de bolsillo (OOPE) declarados por los propios usuarios y el tiempo dedicado a las visitas clínicas durante un proyecto de demostración de la PrEP en Eswatini. En seis clínicas públicas de atención primaria, se entrevistó a 240 usuarios de la PrEP y a otros asistentes a la clínica después de una visita a la misma. Entre el 79,2% de los asistentes a las clínicas que declararon algún OOPE médico (por ejemplo, gastos por consultas o medicamentos) y/o OOPE no médico (por ejemplo, gastos de transporte, comida o uso del teléfono), la mediana del OOPE total fue de 1,36 dólares (IQR: 0,91­1,96). Los gastos no médicos se debieron principalmente a los gastos de transporte. La mediana del tiempo de viaje para una visita a la clínica fue de 1,0 horas (IQR 0,67­2,0). La mediana del tiempo empleado en la clínica fue de 2 horas (IQR 1,15­3,0). La mediana del coste de oportunidad de una visita a la clínica fue de 7,65 dólares (IQR 5,55­11) al valorar el tiempo dedicado a una visita a la clínica con el producto interior bruto per cápita de Eswatini. Nuestros resultados pueden orientar las medidas para reducir los costes de uso de la PrEP en Eswatini y en otros contextos en los que se suministra la PrEP oral a través de los centros de salud.

Reasons for, and factors associated with, positive HIV retesting: a cross-sectional study in Eswatini.

Eswatini has a high HIV prevalence but has made progress towards improving HIV-status awareness, ART uptake and viral suppression. However, there is still a delay in ART initiation, which could partly be attributed to positive HIV-retesting. This study examines reasons for, and factors associated with, positive HIV-retesting among MaxART participants in Eswatini. Data from 601 participants is included in this cross-sectional study. Descriptive statistics and logistic regressions were used. Of the participants, 32.8% has ever retested after a previous positive result. Most participants who retested did this because they could not accept their results (61.9% of all retesters). Other main reasons are related to external influences, gender or the progression of their HIV infection (respectively 18.3%, 10.2%, and 6.1% of all retesters). Participants without a current partner and participants with less time since their first positive test have lower odds of retesting. To decrease retesting and reduce the delay in ART initiation resulting from it, efforts could be made on increasing the acceptance of positive HIV results. Providing more information on the process of testing and importance of early ART initiation, could be part of the solution.

Views of adolescents living with perinatally acquired HIV on HIV status disclosure in Eswatini.

HIV is recognised as a multifaceted chronic disease, bearing psychosocial consequences that potentially impact on the personal and social well-being of those living with it. Adolescents and youth bear a significant proportion of the burden of the HIV epidemic but they have low rates of disclosure of their HIV status. This study aims to determine the views of adolescents living with perinatally acquired HIV on HIV status disclosure among 361 adolescents aged 15-19 in Eswatini. A cross-sectional study was conducted on adolescents who already knew their status, and data were collected using a structured questionnaire. A majority of the participants, 55% (n = 200), were females, and 44% (n = 160) were males. A low number of adolescents (22%) had disclosed their HIV status to anyone. Adolescents who found it difficult to understand disclosure themselves had low levels of onward disclosure (27%) compared to adolescents who better understood the disclosure event. Our results revealed that adolescents' prevalence of HIV status disclosure was low. This raises concerns as some of the adolescents were in relationships with partners who were not aware of their status. However, older adolescents displayed some level of disclosure self-efficacy in that a higher proportion of them disclosed better than younger adolescents.

Body mass index and cervical cancer screening among women aged 15-69 years in Eswatini: evidence from a population-based survey.

BACKGROUND: Cervical cancer stands as one of the most prevalent cancer types among women, despite its preventable nature through early screening and vaccination strategies. The link between being overweight or obese and various adverse health outcomes, including an elevated cancer risk, is well established. Within this study, our central objective was to explore the correlation between body mass index (BMI) and cervical cancer screening (CCS) rates. Moreover, we sought to investigate whether socioeconomic status potentially modulates this relationship. METHODS: Our analysis encompassed 1791 respondents who participated in the World Health Organization's STEPwise approach to noncommunicable disease risk factor surveillance carried out in Eswatini in 2014. We assessed the connection between BMI, along with other determinants, and CCS through both unadjusted and adjusted logistic regression models. RESULTS: The uptake of CCS was 14.4% and the prevalence of overweight and obesity was estimated at 28.1 and 34.9% respectively. After accounting for other pertinent variables, the likelihood of obtaining CCS was amplified for individuals classified as obese (adjusted odds ratio [aOR] = 1.99, 95% confidence interval [CI] = 1.26-3.12) or overweight (aOR = 1.98, 95% CI = 1.05-3.74). Furthermore, factors such as being separated or divorced (aOR = 2.03, 95% CI = 1.11-3.72) and engaging in regular physical exercise (aOR = 3.02, 95% CI = 1.21-6.02) were associated with increased odds of undergoing CCS. CONCLUSIONS: This study underscores the noteworthy role played by both overweight and obesity, in conjunction with various socioeconomic factors, in shaping CCS patterns among the surveyed women. For Eswatini, targeted interventions aimed at enhancing CCS participation should take into account the multifaceted factors highlighted within this investigation.

Non-adherence to cervical cancer screening recommendations among women in Eswatini: a cross-sectional study.

BACKGROUND: In 2018, Eswatini had the world's highest age-standardised cervical cancer incidence rate. Cervical cancer screening reduces women's risk of invasive cervical cancer. Data on adherence to cervical cancer screening recommendations in Eswatini are scarce. The purpose of the current study was to determine Eswatini women's self-reported adherence to cervical cancer screening recommendations, attitudes toward screening, and factors associated with non-adherence. METHODS: A cross-sectional survey of women (n = 377) aged 25 to 59 accessing primary healthcare clinics (n = 4) in Eswatini assessed screening participation, attitudes and knowledge regarding cervical cancer screening, and socio-demographic variables. Adjusted logistic regression was used to assess factors associated with non-adherence to Eswatini cervical cancer screening recommendations. RESULTS: One hundred and sixty-six (44%) women were classified as adherent to cervical cancer screening recommendations. Attitudinal barriers endorsed by over one-third of participants included a perceived low risk of cervical cancer (n = 161, 43%) and a view that screening is likely to be painful (n = 146, 38%). Participants had higher odds of being classified as non-adherent if they: were single compared with married (OR = 1.78, 95% CI: 1.05, 3.01, p = 0.03), perceived screening as likely painful (OR = 4.43, 95% CI: 2.62, 7.46, p < 0.001); and had not been advised by a doctor/ nurse to screen (OR = 2.82, 95% CI: 1.71, 4.64, p < 0.001). Also, a 1-year increase in age was associated with an increase in the odds of being classified as non-adherent (OR = 1.42, 95% CI: 1.39, 1.45, p = 0.01). CONCLUSIONS: Self-reported adherence was moderate among this group of women. Tailored interventions are needed to increase participation in cervical cancer screening, especially for those women with characteristics associated with being classified as non-adherent. Primary healthcare clinic nurses (and other health providers) may contribute toward improving participation in cervical cancer screening by advising eligible women to screen and providing health education addressing negative attitudes toward screening.

Knowledge, attitudes and acceptance of voluntary medical male circumcision among males attending high school in Shiselweni region, Eswatini: a cross sectional study.

BACKGROUND: In countries such as Eswatini, where there is a high HIV prevalence and low male circumcision the World Health Organization and the Joint United Nations Programme for HIV/AIDS recommend infant and adult circumcision be implemented. The aim of this study was to assess the knowledge, attitudes and acceptability of voluntary medical male circumcision amongst males attending high school in Eswatini. METHODS: An observational cross-sectional study was conducted during February and March of 2018 amongst 407 young males (15-21 years) attending Form 4, in nine high schools in the Shiselweni region of Eswatini using a self-administered questionnaire of 42 close ended questions. Sociodemographic details, circumcision status, acceptance of voluntary medical male circumcision, knowledge and attitude scores analysed in Stata® 14 statistical software were described using frequencies, medians and ranges respectively. Bivariate and multivariate linear regression was used to assess the impact of independent variables on circumcision status and acceptance of voluntary medical male circumcision. The level of statistical significance was p < 0.05. RESULTS: Amongst the 407 high school-going males, 48.98% (n = 201) reported being circumcised. The majority of the adolescents (75.74%; n = 306) were knowledgeable about voluntary medical male circumcision. However, an even larger majority (84.90% (n = 343) had a negative attitude towards it. In the multivariate logistic regression analysis, having parented their own children (aOR: 3.55; 95%CI: 1.2-10.48), and having circumcised friends (aOR: 3.99; 95%CI: 1.81-8.84) were significantly associated with being circumcised. Neither knowledge nor attitude were associated with the acceptability of voluntary medical male circumcision. CONCLUSION: In Eswatini male high school students are knowledgeable about voluntary medical male circumcision but have a negative attitude towards it. Having parented their own children, and having circumcised friends influenced being circumcised.

'We Should Not Be Quiet but We Should Talk': Qualitative Accounts of Community-Based Communication of HIV Pre-Exposure Prophylaxis.

Community leaders play an important role in the acceptance of public health services, but little is known about their willingness to facilitate HIV pre-exposure prophylaxis (PrEP) roll-out in Eswatini. We conducted in-depth interviews (n = 25) with purposefully selected male and female community leaders in Eswatini. We analysed our data inductively using a thematic analysis approach. Community leaders feel they are important communicators of culturally appropriate PrEP messaging. Our participants described a complex social space within their communities influenced by religion, tradition, values, and HIV stigma. Community leaders use their position to provide leverage for unique, effective, and easily accessible messages and platforms to reach the community in a manner that ensures trust, relatability, familiarity, and shared faith. Community leaders feel that they are trusted and see trust manifesting in the conversations they are able to engage in, and have a reach that extends beyond formal health services. Existing PrEP programming should embed community leader participation in PrEP programming and engage the trust, knowledge, and potential of community leaders to support PrEP uptake and acceptance.

Eswatini Women´s Knowledge about Cervical Cancer, Data from a Prevention and Awareness Campaign 2021: A Community Based Cross-sectional Campaign.

INTRODUCTION: The increased risk of cervical cancer among HIV+ women is higher compared to HIV - women. A majority of HIV+ care programs offer integrated cervical cancer screening. In Eswatini, the health care system has incorporated two screening modalities, visual acetic acid test and pap smear, into HIV programs. This was a significant strategy to identify women at greater risk for developing cervical cancer. Additionally, leveraging on the trained staff on cervical cancer screening, infrastructure and referral systems for existing services. OBJECTIVE: The aim is to scientifically accompany prevention and awareness campaigns in Eswatini in its real-world settings to obtain (1) a better understanding of cervical cancer knowledge among female participants and (2) to determine the prevalence of screening among women undergoing cervical cancer screening (VIA and Pap smear). METHODS: Community cross-sectional survey among attendees in four regions in Eswatini. Two data collection tools were used: Questionnaires and clinical data from VIA screening. Data were collected from June - October 2021. Age, education and marital status at entry and exit points were assessed to measure the women's awareness of cervical cancer at both points. RESULTS: A total of 450 attendees were interviewed and a total of 414 attendees were screened - 212 through VIA and 202 through pap smear. There was a significant understanding of cervical cancer regardless of education level. A significant variation of more than 90% was observed at the exit point. CONCLUSION: These findings will inform aspects of implementation, including community outreach messaging, health promotion, screening sites and emphasis on accessibility and efficiency of preventative behaviour for women who attend to cervical cancer screening sites.

INTRODUCTION: Le risque accru de cancer du col de l'utérus chez les femmes séropositives est plus élevé par rapport aux femmes séronégatives. La majorité des programmes de soins pour les séropositives offrent un dépistage intégré du cancer du col de l'utérus. Au Swaziland, le système de santé a incorporé deux modalités de dépistage, le test d'acide acétique visuel et le frottis, dans les programmes VIH. Il s'agissait d'une stratégie significative pour identifier les femmes présentant un risque accru de développer un cancer du col de l'utérus. De plus, en tirant parti du personnel formé au dépistage du cancer du col de l'utérus, de l'infrastructure et des systèmes de référence pour les services existants. OBJECTIF: L'objectif est d'accompagner scientifiquement les campagnes de prévention et de sensibilisation au Swaziland dans leur contexte réel pour obtenir (1) une meilleure compréhension des connaissances sur le cancer du col de l'utérus parmi les participantes et (2) déterminer la prévalence du dépistage chez les femmes se soumettant à un dépistage du cancer du col de l'utérus (TAV et frottis). MÉTHODES: Enquête transversale communautaire auprès des participants dans quatre régions du Swaziland. Deux outils de collecte de données ont été utilisés : des questionnaires et des données cliniques du dépistage par TAV. Les données ont été collectées de juin à octobre 2021. L'âge, l'éducation et l'état matrimonial à l'entrée et à la sortie ont été évalués pour mesurer la sensibilisation des femmes au cancer du col de l'utérus aux deux points. RÉSULTATS: Un total de 450 participants ont été interviewés et un total de 414 participants ont été dépistés, 212 par TAV et 202 par frottis. Une compréhension significative du cancer du col de l'utérus a été observée, quel que soit le niveau d'éducation. Une variation significative de plus de 90 % a été observée à la sortie. CONCLUSION: Ces résultats informeront des aspects de la mise en œuvre, notamment la messagerie de sensibilisation communautaire, la promotion de la santé, les sites de dépistage et l'accent mis sur l'accessibilité et l'efficacité des comportements préventifs pour les femmes fréquentant les sites de dépistage du cancer du col de l'utérus. MOTS-CLÉS: Cancer du col de l'utérus, Sensibilisation, Dépistage, Swaziland.

Prevalence and distribution of urinary schistosomiasis among senior primary school pupils of Siphofaneni area in the low veld of Eswatini: A cross-sectional study.

A cross-sectional survey of Schistosoma haematobium prevalence was conducted among senior primary school pupils of Siphofaneni area, Eswatini. This area is devoid of potable water, with a newly constructed Lubovane dam and an LUSIP irrigation scheme. The objective of the study was to investigate the distribution of urinary schistosomiasis among Siphofaneni senior primary school pupils. Using simple random sampling, 200 partcipants were enroled from four of six schools in the area. Ten millimetres (10 ml) of urine samples were obtained from each participant and examined for S. haematobium eggs. The intensity of the infection was estimated by calculating the total number of S. haematobium eggs present in 10 ml urine. Out of 200 participants, 45% (n = 91) were males, and 55% (n = 109) were females. The mean age for participants was 13 years, and almost half (47%, n = 94) were in Grade 5. Overall, the prevalence of S. haematobium infection was 16% (32/200). More than half (59%, 19/32) of the Schistosomiasis cases were from females. Positive and significant associations were observed between the number of eggs (χ2=170.9) and the presence of red blood cells (χ2=49.2) at p = 0.001. In conclusion, the prevalence of Schistosomiasis is high among pupils enrolled in Siphofaneni area primary schools that needs comprehensive treatment and education to prevent from S. haematobium infection.

Cervical cancer screening by visual inspection and HPV testing in Eswatini.

In 2009, visual inspection with acetic acid (VIA) followed by cryotherapy (VIA-and-cryotherapy), was introduced into the Eswatini cervical cancer prevention programme. We present screening results of 654 women attending VIA-and-cryotherapy who participated in a sexually transmitted infections prevalence study, at which samples for HPV DNA testing and liquid-based cytology (LBC) were also collected. VIA positives (VIA+) ineligible for cryotherapy, suspected cancers and women with high-grade squamous intraepithelial or worse lesions (HSIL+) on LBC were referred for diagnosis and treatment. Women with negative VIA who were HPV positive (HPV+) and those VIA+ treated with cryotherapy were recalled for another VIA one-year later. The positivity rates of VIA, HPV, atypical squamous cells of undetermined significance or worse cytology abnormalities (LBC ASCUS+) and low-grade squamous intraepithelial or worse lesions (LBC LSIL+) were 9.7%, 42.6%, 13.2% and 5.3%, respectively. HPV testing detected 29 of 31 LSIL+ (93.6%, 95%CI: 78.6-99.2) while VIA only detected 11 (35.6%, 95%CI: 19.2-54.6). The HIV prevalence was 43% (95%CI: 39.2-46.9). HIV positives were at increased risk of being VIA+ (age-adjusted odds ratio: 2.5, 95%CI: 1.5-4.3), HPV+ (3.7, 2.6-5.3) and having LSIL+ (16.3, 4.9-54.8). The ineligibility rates for cryotherapy were 38% (24 of 63 VIA+), and 46% among HIV positives (18 of 39 VIA+). HPV testing was substantially more sensitive than VIA, thus, HPV followed by ablative treatment may be more effective. However, the high ineligibility for cryotherapy highlights the need for improving the assessment of eligibility for ablative treatment and for strengthening colposcopy, particularly in populations with high HIV prevalence.

PrEP uptake and delivery setting preferences among clients visiting six healthcare facilities in Eswatini.

Due to the high HIV incidence among the general population of Eswatini, pre-exposure prophylaxis (PrEP) for HIV-exposed individuals is recommended. However, little is known about PrEP uptake and preferences in PrEP delivery healthcare setting among the general population. We conducted a secondary analysis of a randomized trial that aimed to increase PrEP uptake. All clients eligible for PrEP in one of six public-sector healthcare facilities in Eswatini were included. PrEP uptake was stratified by initial reason for visit (e.g. outpatient). Preferences in PrEP delivery setting were collected among those clients who initiated PrEP. A total of 1782 clients had their HIV acquisition risk assessed. Of these, 72% (1277/1782) were considered at risk by healthcare providers and, among them, 40% (517/1277) initiated PrEP. Uptake was higher among clients visiting specifically to initiate PrEP (93%), followed by HIV testing visits (45.8%) and outpatient visits (40%). Among those who initiated PrEP, preferred delivery settings were outpatient services (31%), HIV testing services (26%), family planning (21%) and antenatal services (14%). Men or those at high risk of HIV acquisition were more likely to prefer HIV testing and outpatient services, while young women were more likely to visit and express a preference for antenatal and family planning services. Outpatient services and HIV testing services could be preferable choices for PrEP delivery integration, due to the high PrEP uptake and delivery setting preferences of the populations who use these services. Antenatal and family planning could also be considered with a view to targeting the youngest women.

RESUMEN: Debido a la alta incidencia del VIH entre la población general de Eswatini, se recomienda la profilaxis previa a la exposición (PrEP) para las personas expuestas al VIH. Sin embargo, se sabe poco sobre la aceptación de la PrEP y las preferencias en el ámbito de la atención sanitaria de la PrEP entre la población general. Se realizó un análisis secundario de un ensayo clínico que pretendía aumentar la aceptación de la PrEP. Se incluyó a todos los clientes elegibles para la PrEP en uno de los seis centros sanitarios del sector público de Eswatini. La aceptación de la PrEP se estratificó según el motivo inicial de la visita (por ejemplo, paciente externo). Se recogieron las preferencias en el entorno de administración de la PrEP entre aquellos clientes que iniciaron la PrEP. Se evaluó el riesgo de adquisición del VIH de un total de 1.782 clientes (de 2.238 contactados, el 80%). De ellos, el 72% (1277/1782) fueron considerados de riesgo por los profesionales sanitarios y, entre ellos, el 40% (517/1277) iniciaron la PrEP. El consumo fue mayor entre los clientes que acudieron específicamente para iniciar la PrEP (93%), seguido de las visitas para realizar la prueba del VIH (45,8%) y las visitas ambulatorias (40%). Entre los que iniciaron la PrEP, los entornos de prestación preferidos fueron los servicios ambulatorios (31%), los servicios de pruebas del VIH (26%), la planificación familiar (21%) y los servicios prenatales (14%). Los hombres o las personas con alto riesgo de contraer el VIH tenían más probabilidades de preferir las pruebas del VIH y los servicios ambulatorios, mientras que las mujeres jóvenes tenían más probabilidades de acudir a los servicios prenatales y de planificación familiar y expresar su preferencia por ellos. Los servicios ambulatorios y los servicios de pruebas del VIH podrían ser opciones preferibles para la integración de la entrega de la PrEP, debido a la alta aceptación de la PrEP y a las preferencias del entorno de entrega de las poblaciones que utilizan estos servicios. Los servicios prenatales y de planificación familiar también podrían considerarse con vistas a dirigirse a las mujeres más jóvenes.

Girl Champ in eSwatini: A Strategic Marketing Campaign to Promote Demand for Sexual and Reproductive Health Services Among Young Women.

Efforts to engage adolescent girls and young women (AGYW) in HIV services have struggled, in part, due to limited awareness of services and stigma. Strategic marketing is a promising approach, but the impact on youth behavior change is unclear. We report findings from a mixed methods evaluation of the Girl Champ campaign, designed to generate demand for sexual and reproductive services among AGYW, and piloted in three clinics in the Manzini region of eSwatini. We analyzed and integrated data from longitudinal, clinic-level databases on health service utilization among AGYW before and after the pilot, qualitative interviews with stakeholders responsible for the implementation of the pilot, and participant feedback surveys from attendees of Girl Champ events. Girl Champ was well received by most stakeholders based on event attendance and participant feedback, and associated with longitudinal improvements in demand for HIV services. Findings can inform future HIV demand creation interventions for youth.