Swaziland Dramatically Reduces HIV Incidence Through Test-and-Treat Programs

Velephi Okello, deputy director of Health Services-Clinical Services, Ministry of Health- Swaziland
Marcus Rose/IAS

Swaziland, a small, landlocked country located northeast of South Africa, has the highest per capita burden of HIV in the world, with nearly 26% of people ages 15 to 49 infected, according to a 2015 estimate from the U.S. Centers for Disease Control (CDC).

However, over the last decade, the country's government, which is ruled by a monarchy, has created an ambitious treatment and prevention program in partnership with a number of international organizations, such as the President's Emergency Plan for AIDS Relief (PEPFAR) and the CDC.

Now, according to results of a countrywide survey presented at the 2017 IAS Conference on HIV Science in Paris, France, the Kingdom of Swaziland has dramatically reduced the number of new HIV infections while simultaneously getting a substantial portion of the HIV-positive population on treatment.

"I'm happy to share great news from the Kingdom of Swaziland," said Velephi Okello, M.B.B.S., M.P.H., deputy director of Clinical Services at the Ministry of Health, Swaziland, speaking during an IAS panel. "The survey showed that the rate of new HIV infections has been reduced by half, and the proportion of adults living with HIV who have controlled or suppressed HIV infection has been doubled," said Okello.

Swaziland's first population-based HIV impact assessment survey (SHIMS1), was conducted in 2011. The second survey, SHIMS2, included more than 14,000 children and adults who agreed to be interviewed and provide blood samples, according to the study press release.

"The SHIMS2 survey was an opportunity for us as a country to measure the impact of our strategies that we've put in place to control the HIV/AIDS epidemic in terms of HIV prevention and treatment," said Okello.

In SHIMS1, the rate of new HIV infections every year among adults ages 18-48 was 2.48%. In SHIMS2, the rate had dropped by half to 1.39%. For adults older than 15 years of age, the average rate of new infections was 1.70% among women and 1.02% among men, indicating that women remain a vulnerable population.

In fact, the government's treatment-as-prevention strategies have contributed to a dramatic drop in new HIV infections. The SHIMS2 survey showed a marked uptick in the number of HIV-positive people who are on treatment, and therefore, more people living with HIV are not able to transmit the virus.

For example, in 2011, only 34.8% of HIV-positive people ages 18-49 in Swaziland had achieved viral load suppression. However, the survey revealed that, by 2017, 73.1% of HIV-positive people were virally suppressed. A higher portion of women (76%) than men (67.6%) had achieved viral suppression by 2017.

So, how did Swaziland do it? According to a press release, the improved control of the epidemic is thanks to a massively expanded testing-and-treatment program. These efforts were led by the government of the Kingdom of Swaziland, funded by PEPFAR and implemented by the CDC and the International Center for AIDS Care and Treatment Programs (ICAP). Founded at Columbia in 2003, ICAP is a group that provides technical support to governments implementing public health programs for HIV, tuberculosis and other diseases.

"While we do celebrate the success of these findings, we know that Swaziland is facing a severe HIV epidemic," said Okello during the IAS panel presentation. "But we are just encouraged by these findings, and as the government of the kingdom of Swaziland, we are going to build on these successes so we can put more vigor and increase our response[.]"

"In the end," said Okello, "we'd like to see a Swaziland that is free from AIDS."