Making a difference
Decentralisation of
HIV/ TB carein Shiselweni regionof Swaziland
Summary Evaluation Report
December 2013

Summary Evaluation Report – December 2013

Making a Difference – Decentralisation of HIV/ TB Care in Shiselweni Region of Swaziland

1

LIST OF Abbreviations

AIDS

Acquired immunodeficiency syndrome

ART

Antiretroviral treatment

ARV

Antiretroviral

CD4

Cluster of differentiation 4, human immune system

CTS

Community treatment supporters

DOTS

Directly observed treatment, short-course

DR-TB

Drug-resistant tuberculosis

DS-TB

Drug-sensitive tuberculosis

DST

Drug sensitivity test

EAAA

Early access to ARV for adults

GDP

Gross domestic product

HCWM

Health care waste management

HTC

HIV testing and counsellingHIV

Human immunodeficiency virus

ICER

Incremental cost-effectiveness ratio

IMAI

Integrated management of adolescent and adult illness

LTFU

Lost to follow-up

MCH

Mother and child health

MDR-TB

Multidrug-resistant tuberculosis

MoH

Ministry of Health

MSF

Médecins Sans Frontières

MSF-CH

Médecins Sans Frontières Switzerland

MTB

Mycobacterium tuberculosisNGO

Non-governmental organisation

NTSF

National Task-Shifting Framework

OI

Opportunistic infection

PDR-TB

Polydrug resistant tuberculosis

PHCC

Primary health care clinics

PHU

Public health unit

PLWHA

People living with HIV/AIDS

PMTCTPrevention of mother-to-child transmission

PMTCT B+ Prevention of mother-to-child transmission, option B+
POC

Point-of-care

PTB

Pulmonary tuberculosis

RIC

Retention in care

SHCF

Secondary health care facility

SNAP

Swaziland National AIDS Programme

SRHU

Sexual and reproductive health unit

TB

Tuberculosis

TLA

Thin-layer agar

UNDP

United Nations Development Programme

UNAIDS

Joint United Nations Programme on HIV/AIDS

VCT

Voluntary counselling and testing

VL

Viral load

WHO

World Health Organisation

XDR-TB

Extensively drug-resistant tuberculosis

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Making a Difference – Decentralisation of HIV/ TB Care in Shiselweni Region of Swaziland

Summary Evaluation Report – December 2013

Making a difference
Decentralisation of
HIV/ TB carein Shiselweni regionof Swaziland
Summary Evaluation Report
December 2013<<
Jimson Bhembe a HIV positive patient on ART
referred for treatment by Traditional Healerin Mnyatsini village in the Shiselweni region,
south of Swaziland.
<
MSF staff addressing the community

during the Dip Tank community testing
campaign at Nhletsheni, in Shiselweleni
region, south of Swaziland.

Summary Evaluation Report – December 2013

Making a Difference – Decentralisation of HIV/ TB Care in Shiselweni Region of Swaziland

3

4

Making a Difference – Decentralisation of HIV/ TB Care in Shiselweni Region of Swaziland

Summary Evaluation Report – December 2013

Table of contents

Summary Evaluation Report – December 2013

List of abbreviations
List of figures

2
6

1

EXECUTIVE SUMMARY

72Introduction

8

3

DESIGN & IMPLEMENTATION
OF THE HIV/ TB SHISELWENI PROJECT

10

3.1
3.2
3.3
3.4
3.5
3.6

Overview of the decentralisation model
10
Developing and task-shifting human resources for health care 13
Advocating for supportive health policies and sufficient funding 13
Achieving decentralisation
14
Improving infrastructure & infection control
15
Innovating and decentralising diagnostic technologies
17

4

PROGRAMME OUTCOMES

18

4.1
4.2
4.3
4.4
4.5
4.6
4.7
4.8

Increased uptake of HIV testing
Increased access to ART
Improved retention in care (RIC)TB spread & shift of treatment initiation to PHCC
Improved treatment outcomes for DS-TB patients
Improved access to DR-TB treatment
Reduced incidence of opportunistic infections
Decreased crude mortality rate

18
19
20
21
22
23
24
25

5

PERCEPTION & ACCEPTABILITY
OF DECENTRALISED HIV/ TB CARE

27

5.1
5.2
5.3
5.4

Perceptions of the model & its impact on patient care
Increased motivation for staff
Acceptance of community activities
Speed of implementation versus engagement with authorities

27
28
28
29

6

PERCEPTION OF REMAINING CHALLENGES

30

6.1
6.2

StigmaContinuity

30
30

7

COST EFFECTIVENESS

33

8RECOMMENDATIONS

34

8.1
8.2

At project level
At country level

34
34

9

FUTURE PERSPECTIVES : INCORPORATING“TREATMENT AS PREVENTION” STRATEGIES35

10ACKNOWLEDGEMENTS

37

11

References	

38

Making a Difference – Decentralisation of HIV/ TB Care in Shiselweni Region of Swaziland

5

LIST OF figures

Figure 1

Map of Swaziland

Figure 2

Timeline of implementation steps in decentralisation project

Figure 3

Greater decentralisation is linked to improved access tohealth care

Figure 4

The TB ward in Nhlangano health centre

Figure 5

Point-of-care diagnostic technologies implemented at
PHCC level

Figure 6

HIV & TB diagnostic technologies introduced at theregional level

Figure 7

Increase in HTC uptake over time 2009-2012

Figure 8

New ART initiations over time 2008-2012

Figure 9

Improved retention in care over time 2008-2012

Figure 10 Retention of ART patients at 6 month after

treatment initiation

Figure 11 Annual TB incidence & estimated ART coverage inShiselweni 2007-2012

Figure 12 TB treatment initiations at PHCC 008-2013
Figure 13 Drug-sensitive tuberculosis (DS-TB) cure rates 2009-2012
Figure 14 Drug-resistant tuberculosis (DR-TB) 24-month

regimen outcomes

Figure 15 Numbers of HIV proxy conditions (regardless of HIV status)
diagnosed at outpatient departments 2007-2012 in SHCF
& PHCC combined
Figure 16 Estimated crude mortality rate (inpatient & outpatient)in Shiselweni region<
A MDR-TB patient during a home visit
at Mbulwane, in Shiselweni.

1

Swaziland is a small, sub-SaharanAfrican country with a populationof only 1.2 million people and oneof the world’s highest rates of both
HIV prevalence and new TB infections. Since the early 1990’s, whenthese two diseases took root in the
country, life expectancy has plummeted by more than 11 years. To
support Swaziland in responding
to this dual epidemic, in 2008 MSF
Switzerland (MSF-CH) launched an
HIV/ TB project in the rural region of
Shiselweni. The project was basedon a strategy of decentralisingcare to the primary facility andcommunity levels by building local
clinical and laboratory capacity,and expanding human capacity
by shifting the provision of care tolower cadres of health workers.
In early 2013, MSF conducted aretrospective assessment of thefirst five years of the Shiselweni
HIV/ TB programme. The evaluation
involved reviewing patient outcomes, infrastructure and humanresource development, costeffectivness, advocacy efforts, andperceptions of the various local
and national stakeholders. In thisreport we present the results of
our assessment and describe thelessons learned—including successes and failures—to the entire
MSF movement, to local actors
in Shiselweni, to Swaziland’snational authorities, and to theinternational community.
Overall, this evaluation found that
decentralisation of activities tothe primary health care clinic andcommunity levels greatly improved
access to diagnostic and treatment
services for HIV and TB patients.
By 2012, Shiselweni had reached
universal ART coverage (as defined by WHO 1 )—a major increase
relative to the baseline of only 17 %coverage in 2006, before decentralisation was implemented.

EXECUTIVE SUMMARY
This expanded access was associated with a steady improvementof treatment effectiveness overthe five-year period. ART outcomes
for the region improved consistently at every follow-up time point
assessed (6, 12, 18 and 24 months),
with a trend towards better coverage and long-term retention at
primary health care clinics compared with secondary health carefacilities. TB treatment shifted toprimary care clinics also showed aclear trend towards better treatment outcomes among drug-sensitive TB patients at both health carelevels. A steady decrease in theburden of TB and other HIV-related
opportunistic infections (the main
health risk for Swaziland’s HIVpositive population) over the periodof 2008-2012 correlated well withthe reduction of crude mortality in
Shiselweni during this time.
The example of Shiselweni thus
demonstrates that, in a context
of high HIV and TB prevalence andlimited resources, decentralisation of care from regional anddistrict hospitals to primary healthcare clinics and communities is ahighly effective way to improve thequality of care and the efficiencyof service delivery. It also improves
patient satisfaction and acceptance of health service providers bydirect beneficiaries and the wider
community. A separate analysis ofcosts found that decentralisation
is highly cost-effective from theservice provider perspective andallows for a better use of resources
than do centralised care strategies.

The key to successful decentralisation of HIV and TB services in the
Shiselweni project was strengthening human capacity for providing
care, via a strong, well-implemented
task-shifting component. Inclusionof lay people as service providers,in particular people living with
HIV/AIDS and TB, improved theacceptance of medical services
by affected populations. It also
decreased stigma, a crucial barrier
to accessing care, and improved
both the self-esteem of affected
populations and their acceptance by the community. Other key
ingredients of success for the
Shiselweni decentralisation model
included implementation of morerobust infection control measures,
adaptation of laboratory services to the needs of an expanded,
low-resource health care system,
and advocacy to ensure strong
commitment from all stakeholders
in terms of supportive policies,
best practices, and effective funding mechanisms.
In conclusion, decentralised
health care with task-shifting inShiselweni resulted in improved
patient access to care and better treatment outcomes. It also
strengthened human resources inhealth care and empowered PLWHA
and the wider community. Throughlowered burden of opportunistic
infections it also most likely contributed to the overall reductionof mortality in the region. During
the next phase of the programme,
which will incorporate “treatment
as prevention” strategies, this
now-established model of carehas the potential to accelerate thegains achieved and thus begin toturn back the HIV and TB epidemics
that have cost tens of thousands of
lives in Swaziland.

>
1 80 % of population in need of ART treatment, based on
having a CD4 count < 350 (WHO definition).

MSF Expert Client during a pre HIVtest counselling session with a local
youth at MSF Dipping Tank community
testing campaign at Nhletsheni, in
Shiselweleni region, south of Swaziland.

Summary Evaluation Report – December 2013

Making a Difference – Decentralisation of HIV/ TB Care in Shiselweni Region of Swaziland

72

Introduction

HIV/AIDS and tuberculosis (TB) continue to pose major challenges to socioeconomic developmentin Swaziland. It is widely recognised that reversing the country’s high HIV/ TB burden and meetingthe demand for equity of care requires scale-up and decentralisation of HIV and TB services to thecommunity level. This approach has proven its effectiveness in many contexts worldwide (MSF 2010,2011). Beyond the obvious impact of ART on saving lives and alleviating suffering, recent evidence

demonstrates unequivocally that treatment also works as prevention, which in turn can slow the
epidemic’s spread (Cohen et al, 2011). The decentralisation approach to delivering HIV services has
been broadened to integrate HIV and TB care, especially in resource-limited settings (Fraser 2007).

The challenges associated with decentralisation have also been documented. They include :increased demand for already limited resources (e.g., quantity and quality of human resources ;laboratory capacity), financial burden and lack of accountability, lack of community engagement insome settings, political conflict between different levels of the health care system, and long-termsustainability (Rasson et al, 2011).
Swaziland, with a population of 1.2 million people (SPP 2007), is a small, mountainous country,
landlocked by South Africa and Mozambique, and is one of three remaining monarchies in Africa.
The Kingdom is in 142nd place on the human development index of 2012 (also 142nd in 2007), withan estimated 40.6 % of its population living on less than US$ 1.25 per day—62.9 % in 2007—(UNDP
2009, 2013). The country has the highest HIV prevalence in the world among adults aged 15 to49 years : 26.5 % in 2012, slightly higher than 25.9 % in 2007 (SDHS 2007, UNAIDS 2012) and oneof the highest rates of new TB infections, estimated at 1,349 new cases/100,000 population/year(WHO 2013). The dual epidemic of HIV and TB has contributed substantially to a significant reduction of life expectancy over the past two decades—from 60 years in the early 1990s to 48.9 in 2012
(UNDP 2013).
Against this context, a decentralisation project was initiated in 2007 in Shiselweni, the region of
Swaziland with the least health care infrastructure and poorest overall health outcomes. Following
a four-month assessment, MSF-CH signed a memorandum of understanding with the Ministryof Health to provide care throughout the Shiselweni region for people with HIV and TB, including
drug-resistant TB (DR-TB).
The 2007 assessment identified several key problems the programme needed to address immediately : chronic shortages of health care staff, absence of integrated HIV/ TB services, and limitedaccess to care, due to highly centralised services and inadequate capacity to extend HIV/ TB care
into primary clinics. Over the next five years, MSF and its local partners implemented a plan that
integrated and shifted HIV and TB care to 22 local clinics, where approximately 15,500 HIV patientsand 10,500 TB patients have been treated as of the end of 2012.
At the end of five years, i.e., in early 2013, MSF conducted a comprehensive evaluation of the
project in Shiselweni. The main objective was to evaluate the appropriateness, effectiveness andefficiency of the decentralised HIV/AIDS & TB care model over the period from 2008 to 2012.
The evaluation was conducted as a series of independent studies. These were :• Literature research on decentralisation models and on-the-ground experience in resource-limited
African contexts.
• Study of perceptions about the programme among different stakeholders—MSF, health care staff,
national authorities, international actors, patients and the wider community.
• Description of the decentralisation model adapted in Shiselweni region, and analysis of the programme outcomes in the wider public health context of Swaziland.
• Cost-effectiveness analysis of HIV service provision in primary health care clinics (PHCC) versus
secondary health care facilities (SHCF).
• Analysis of the implementation of innovative and decentralised laboratory services.
• Analysis on infrastructure development and infection control strategies.
The detailed methodologies of these studies are described in separate reports. This report summarises and discusses the implications of the key findings that emerged from these individual studies.

8

Making a Difference – Decentralisation of HIV/ TB Care in Shiselweni Region of Swaziland

Summary Evaluation Report – December 2013

DESIGN & IMPLEMENTATION OF
THE HIV/ TB SHISELWENI PROJECT
3

3.1 Overview of the decentralisation model
In 2008 when MSF started its intervention in Swaziland, only 24 sites in the wholecountry (3 in Shiselweni) provided ART. Task-shifting was just beginning, withnurses to expert patients 2 being the only shift slowly implemented.
To achieve the specific objective of the project—i.e., improved prevention,
diagnosis and treatment of HIV and TB—MSF proposed to the Ministry of Health(MoH) a decentralised care approach that incorporated the following strategies :• Providing HIV and TB diagnosis and treatment at both the SHCF and PHCC levels ;• Implementing HIV viral load monitoring and TB sensitivity testing (for both diagnosis & monitoring) at region level ;• Implementing HIV diagnosis and HIV/ TB follow-up at the community level ;• Reinforcing patient support, education and counselling, led by expert patients 3 ;• Adopting effective task-shifting strategies, including nurse-led ART and TB care
at all health facilities ;• Decentralising laboratory capacity and introducing new point-of-care technologies to increase PHCC diagnostic and monitoring capacity ;• Improving the infrastructure to facilitate patient-flow and accommodate increased workload ;• Improving infection control measures in PHCC and at the community level ;• Establishing effective referral system of patients and laboratory samples between the different levels of care ;• Supervising staff performance at every PHCC ;• Engaging with communities, to ensure effective linkage with health facilities ;2 Also known in Swaziland as Expert Clients—HIV-positive
patients who have disclosed their status and work in HIV
care, mainly to provide HIV counselling and patient support.

• Incorporating innovation and conducting operational research, in order to apply
the latest evidence to the specific context and needs of Shiselweni, and to facilitate the uptake of effective new policies.

3 Greater Involvement of People living with HIV/AIDS :translated through patient treatment literacy and patient
empowerment toward the disease.

Additionally, MSF presented the Ministry of Health (MoH) with a specific proposal
to tackle TB (including DR-TB) in Shiselweni region :• Constructing a TB Ward in Nhlangano (completed in 2011) ;• Initiating a decentralised DR-TB community treatment programme ;• Updating national TB guidelines, based on results of the National TB DST Survey
conducted by MSF and Epicentre in 2010 ;• Improving diagnostic laboratory services ; and• Introducing second-line TB drugs throughout the region through a Green Light
Committee mechanism.
Implementation of this plan required efforts on many fronts, described elsewhere in this document. These included : rolling out a well-designed strategy oftask-shifting to nurses and to newly-created health worker cadres (see section
3.2) ; creating a supportive policy environment through engagement with the
Ministry of Health and advocacy with other actors, both in-country and external(see section 3.3) ; developing the necessary infrastructure in the health facilities
and ensuring their capacity to implement adequate infection control (see section 3.5) ; and improving diagnostic capacity at both the primary and secondary
facility levels (see section 3.6).

10

Making a Difference – Decentralisation of HIV/ TB Care in Shiselweni Region of Swaziland

Summary Evaluation Report – December 2013

SWAZILAND
Districts boundaries

SOUTH AFRICA

National capital
District capital010

20 kilometers
10

20 miles

MOZAMBIQUE

Piggs Peak

HHOHHO
MbabaneManzini

Siteki

LUBOMBO

MANZINI

Hlatikulu

SHISELWENI
SOUTH AFRICA

Map of Swaziland
Figure 1
Summary Evaluation Report – December 2013

Making a Difference – Decentralisation of HIV/ TB Care in Shiselweni Region of Swaziland

11

a
Nhl

DECEMBER 2012

nga

no

Full implementation & integration of HIV/TB
services in 22 clinics at PHCC level.
The use of Viral Load is decentralised from centrallevel (Mbabane) to district level (Nhlangano).
ne

NOVEMBER 2010

Mbaba

Patients are initiated on antiretrovirals
at CD4 count of 350.

SEPTEMBER 2011

Inauguration of the Nhlangano TB ward.

MARCH 2010

JULY 2009

Mini laboratories arelaunched in clinics.

Integration of TB & HIV
services at PHCC level.

JUNE 2010

SEPTEMBER 2009

Nurses initiate patients on ART.

Task-shifting is used when initiating
patients on antiretrovirals.

JUNE 2008

Task-shifting for antiretroviraltherapy (ART) follow up.
Expert Patients begin working
at PHCC level and throughcommunity outreach activities.

JUNE 2009

Start of community Drug Resistant
Tuberculosis (DR-TB) treatment.

DECEMBER 2007

Figure 2
12

ShiselweniTimeline of Implementation
Steps in Decentralisation Project

MSF starts the implementationof the decentralised model of carein the region of Shiselweni.

Making a Difference – Decentralisation of HIV/ TB Care in Shiselweni Region of Swaziland

Summary Evaluation Report – December 2013

3.2 Developing and task-shifting

human resources for health care
Task-shifting was implemented in Shiselweni using a
step-by-step approach (see figure 2), with three levels ofdecentralising HIV/ TB care from SHCF to the 22 PHCC of
Shiselweni region :• Doctors to nurses ;• Nurses to HIV/ TB patients (expert patients) ; and• Nurses to community members.
Doctors to nurses : At the start of the programme, only
doctors were authorised to prescribe and follow up HIV
and TB patients, while nurses focused on HIV testing andcounselling. The initial tasks shifted from doctors to nurses
were ART refill and patient follow-up, followed by ART
initiation and then TB initiation, DS-TB management and OI
management (Integrated Management of Adolescent andAdult illness, IMAI WHO training course). Today, all nurses
have the authority and skills to fully manage ART and DS-TB
at PHCC level, from detection and diagnosis to treatment
and follow-up.
Nurses to HIV/ TB patients (expert patients) and community
members : At the beginning of Swaziland’s HIV/ TB epidemic,
clinic nurses found themselves overloaded and inadequately equipped to effectively support growing numbers of patients. Task-shifting from nurses to lay people was initiatedto help meet this challenge, with expert patients deployed
first in the clinics and later in the community. Over time,
additional tasks were successfully shifted from nurses tophlebotomists (laboratory assistants), pharmacy assistants
and Community Treatment Supporters (CTS). People Livingwith HIV/AIDS (PLWHA) were prioritised in the selection oflay cadres, since their involvement in delivering care helps
support their personal empowerment, build links to thecommunity, and reduce stigma.
Early in the programme, informal and on-the-job trainings
in Shiselweni helped kick off task-shifting among the different layers of health workers. However, formal training andaccreditation proved to be important for official recognitionby the MoH and for future absorption of these cadres into
the health care system. Our analysis indicated that supportive supervision methods, implemented mostly by MSF,
were adequate and effective ; however, the need to include
more MoH staff in the supervisory teams was highlighted.

Summary Evaluation Report – December 2013

3.3 Advocating for supportive healthpolicies and sufficient funding
Advocacy and lobbying played an important role in helping
to generate awareness and support of the decentralisation
strategy, and to translate it into policy. The foundation ofthese activities was built on evaluating patient and programmatic outcomes, which over time clearly demonstrated
the success of the approach. MSF’s active participationin preparing the MoH National Task-Shifting Framework,
which was finalised at the end of 2011, was another key element of the advocacy strategy. All health worker cadres that
had been introduced into the Shiselweni project (pharmacy
assistants, lab assistants, HTC counsellors, expert patients,and health motivators in the community), were incorporated
into this framework. The framework calls for measures thatare now common practice throughout the country.
Another focus of policy work to support HIV/ TB programmes
was to provide input into the country’s Global Fund applications, an effort that started soon after MSF began working
in Swaziland on HIV/ TB. During 2011 we contributed to theapplication for Round 11 funding, which was subsequently
cancelled due to lack of money—a situation that triggered aseries of lobbying efforts at the national level, and of public
positioning at the national and southern African regional
levels. At the same time MSF participated in public events(demonstrations, etc.) in South Africa to raise awarenessand protest against this cancellation.
Several other advocacy efforts were undertaken along theway, as needed to support the overall programme. In 2009,
MSF lobbied for a new ARV (tenofovir) to be included infirst-line HIV treatment and for the country to adopt the
new WHO guidelines endorsed in 2010. The following year,
MSF worked to update the National DR-TB Guidelines basedon our experience in Shiselweni. In 2011, MSF worked with
PLWHA organisations to raise public awareness about theconsequences of ARV stock-outs on the life of the patients.
During 2012, MSF and collaborators worked on the Human
Resources for Health Strategic Plan and also finalised the
National Treatment as Prevention Framework. That same
year, viral load monitoring was introduced in Shiselweni ;the outcomes will be used to help shape future policies andguidelines. Innovative laboratory diagnostic methods like
GeneXpert®MTB /RIF (2011) and TLA (2012) for diagnosing
DR-TB were also put in place, demonstrating the feasibilityof decentralising laboratory diagnostic and follow-up
of patients.

Making a Difference – Decentralisation of HIV/ TB Care in Shiselweni Region of Swaziland

13

Grea

ter Dece nt ral i sations to Health Cas to He alth Ca

Acces

re

Community

re

Acces

Primary HealthCare Clinics

HospitalisFigure 3

Lin

ked

to Be

tter Access to He

al

a
th C

re

3.4 Achieving decentralisation
Due to the concerted efforts of MSF and the national and regional authorities,
decentralisation proceeded gradually, leading to impressive results by the end of
the five years period. Treatment and care for HIV/AIDS and drug-sensitive DS-TB
were fully decentralised to the region’s 22 primary health care clinics. What
started as two separate programmes for HIV and TB is now fully integrated into
PHCC, ensuring the provision of much-needed “Point-of-Care” (POC) services
for patients. Moreover, most HIV and TB follow-up services are available at thecommunity level.
Even DR-TB diagnosis and treatment has been decentralised, improved andexpanded, through building capacity of the staff, adding new infrastructure(Nhlangano TB ward) with innovative infection control measures (incorporating
natural ventilation), and introducing community services to follow up patientscloser to their homes. The region also developed capacity to diagnose DR-TB andto follow resistance patterns, thanks to the implementation of diagnostic technologies such as GeneXpert®MTB /RIF and TLA—making the area self-sufficient.
Laboratory service was to a large degree decentralised and integrated into
the clinics via mini-labs, and linked to the SHCF through transport system forsamples. Achieving continuity in drug and medical supply was another importantcomponent of decentralisation, as was equipping the medical facilities withimproved infection control measure such as adequate ventilation and waste
management systems, and improving space /patient flow.

14

Making a Difference – Decentralisation of HIV/ TB Care in Shiselweni Region of Swaziland

Summary Evaluation Report – December 2013

3.5 Improving infrastructure& infection control
To reinforce transmission control at health facilities andwithin the community, the Shiselweni project put in placevarious infection control mechanisms. These new measuresinvolved infrastructure improvements at all three levels of
health care provision : at the secondary health care level in
Nhlangano Health Centre, which houses a TB Ward for MDR
and XDR-TB patients and a TB microbiology laboratory ; atthe primary health care level, in the clinics of Shiselweni
region ; and at the community level, in the homes of
DR-TB patients.

Figure 4

The TB ward in Nhlangano health centre

Secondary health care level
The DR-TB ward (see figure 4) was built next to the existing
health centre in Nhlangano. It comprises of 30 small andmedium-sized rooms that encompass an inpatient department, including a unit for critical and palliative care, andan outpatient department for diagnosis and follow-up. A
sustainable design integrates the exclusive use of natural
cross-ventilation ; for better infection control, patient flow
is organised according to the transmission risk level.

Primary health care level
Numerous infrastructure improvements in the clinics
included the building of outdoor waiting areas, extra consultation rooms (equipped with accelerated air flow fromoutside) adjacent to the clinics, and Health Care Waste
Management (HCWM) systems.

Community level
To decrease DR-TB transmission in communities, theprogramme worked with community members to install
windows and doors at patients’ home, thereby improving
ventilation, and to build separate patients rooms whenneeded, according to infection control rules.

Summary Evaluation Report – December 2013

Making a Difference – Decentralisation of HIV/ TB Care in Shiselweni Region of Swaziland

15Figure 5(1)

Point-of-care diagnostic technologies implemented at PHCC level

Alere Pima™
(2)

Reflotron®Plus(3)

HemoCue 201®

(4)

Figure 6
HIV and TB diagnostic technologies introduced at the regional level

GeneXpert®MTB/RIF

16

Making a Difference – Decentralisation of HIV/ TB Care in Shiselweni Region of Swaziland

Summary Evaluation Report – December 2013

3.6 Innovating and decentralising

diagnostic technologies
Strengthening laboratory services and adapting them tothe low-resource environment represented another key
strategy of the decentralisation programme. This strategy
was implemented on two levels : ensuring that PHCC havethe necessary diagnostic capacity to support HIV/ TB scaleup, and reinforcing diagnostic capacity at the regional level.
management systems, and improving space/patient flow.

Ensuring the diagnostic capacityof PHCC through “mini-laboratories”
Starting in 2010, MSF introduced several innovative diagnostic approaches to the PHCCs by introducing POC technologies that could be operated by trained lay personnel(phlebotomists) with minimum supervisory support.
These POC diagnostics included (see figure 5) :• CD4 POC instrument (Alere Pima™) (1)Measures CD4 cell count from blood, information which
both WHO and national guidelines use as a key factor in
identifying which HIV-positive individuals should be initiated on ARV.
• Biochemistry POC (Reflotron®Plus) (2)Performs clinical chemistry tests (creatinine, glucose, potassium and ALAT).
• Haematology POC (HemoCue 201®) (3)Measures haemoglobin level using blood from a finger prick.
These selected low-complexity POC technologies could
be maintained at the clinic level with only minor support,
which was provided by a mobile laboratory technologist.
Quality assurance was implemented by both internal andexternal control mechanisms. Programmatic experience
with these three POC technologies has demonstrated their
good performance in field conditions within the Shiselweni
context, indicating the feasibility of transferring them tosimilar settings. Prior to a transfer, an assessment of thetechnical reliability of laboratories and the availability ofhuman resources should be conducted.

Improving diagnostics
at the regional level
In parallel to these improvements at PHCC, latest-generation technologies for early detection of MDR-TB and formonitoring HIV viral load (VL) in patients on ART were implemented at the regional level. Together with an effective
sample transportation system from PHCCs to the referencelaboratory, these measures meant that rural populations
could have timely access to the following diagnostics :• HIV Viral Load Test (Biocentric method)
Suppression of VL is the key reason for using ART, and VL
level is the best direct indicator of how well an HIV patientis responding to treatment. Establishment of this technology in the Nhlangano referral laboratory therefore makes avitally important test available to the region’s ART patients.
• GeneXpert®MTB/RIF (Cepheid®) (see figure 6) (4)The GeneXpert® analyser delivers a very fast and accurate
diagnosis of both DS- and DR-TB (the latter by also detecting resistance to rifampicin, one of the first-line TB drugs).
Although it has some limitations, GeneXpert® technology
is a vast improvement over other TB diagnostics in terms ofspeed, accuracy, and reduction of clinic staff workload.
• Thin Layer Agar (TLA)This method, which was introduced into the Nhlangano
TB laboratory, makes it possible to perform more rapid TB
culture-based diagnoses and drug sensitivity (DS) tests (todetect resistance to TB drugs other than rifampicin) compared with most other tests. In 2013, MSF, the MoH and theInstitute of Tropical Medicine (Antwerp, Belgium) began theprocess of validating TLA testing with second-line TB drugs(ofloxacin and kanamycin) for the rapid detection of XDR-TB.

Summary Evaluation Report – December 2013

Making a Difference – Decentralisation of HIV/ TB Care in Shiselweni Region of Swaziland

17

4

Increase in HTC Uptake Over Time

14,00012,00010,000PROGRAMME OUTCOMES

2009-201230%
26% 25% 26% 25%

8000

2000
0

Figure 7

11,052
21%

6000
4000

Total number HTC done
Total number HIV positive% HIV positivity at HTC

19% 19% 18%

17%

16%

2115

17%

16%

14% 13%
11%

640
2009

1200
2010

2011

2012

4.1 Increased uptake of HIV testing
Decentralisation of HIV services and greater focus on provider-initiated testing (vs VCT) led to an increase of morethan 500 % in the uptake of HIV testing and counselling(HTC 4 ) between the beginning of 2009 to the end of 2012, asshown in figure 7. During this same time period, the proportion of HIV-positive people identified at HTC decreased
from 30 % to 11 %, indicating that more HIV-negative people
were accessing HTC. At the end of 2012, most of the HTC(70 %) was performed at PHCC and community level and theremaining (30 %) at SHCF.
WHO recommendations and national guidelines call for HIVnegative people to undergo HIV testing once a year (WHO2010 ; MoH 2010). Coverage of annual HTC in Shiselweni wasestimated at 10 % in 2009, and increased to more than 20 %in 2012. However, despite this welcome improvement, thesenumbers remain low and point to the need for additional strategies that reach a wider population and improve
HTC uptake.

4 Provider-initiated testing is also known as PITC : Provider-Initiated HIV Testing & Counselling, referring to HIV testing and counselling which is routinely recommended by health care providers to persons
attending health care services. Voluntary Counselling & Testing refers to HIV testing and counselling
being sought by individuals on their own initiative. HTC includes both, PITC and VCT.

18

Making a Difference – Decentralisation of HIV/ TB Care in Shiselweni Region of Swaziland

Summary Evaluation Report – December 2013

5000
4500

New ART Initiations Over Time2008-2012

4000
3500
3000
2500
2000
1500
1000
500
0

2008

2964

Figure 8

2009

3716

2010

4328

2011

3930

2012

3579

4.2 Increased access to ART
Improved access to HIV/ TB care through rapid scale-up and decentralisation
across the region (2009-2010), as well as changes in national HIV treatment
guidelines (earlier ART initiation—at CD4 ≤ 350 instead of 200—and ART for all TB
co-infected patients, regardless of CD4 count, since 2009), were the main factors
behind an increase in annual ART initiations before 2010 (see figure 8) (MoH2010).
Estimates from Shiselweni indicate that “universal” ART coverage—defined by
WHO as ART coverage that reaches > 80 % of patients in need of treatment—was
achieved in 2012 (vs. 17 % in 2006). Throughout this period, the PHCC provided
treatment for an increasing proportion of the region’s ART cohort, managing morethan half of all patients by 2012.

Summary Evaluation Report – December 2013

Making a Difference – Decentralisation of HIV/ TB Care in Shiselweni Region of Swaziland

19

Improved Retention
in Care Over Time

Retention of ART Patients at
6 Months After Treatment Initiation% ART patientsin care6 months
12 months
18 months
24 months
36 months

52008-2012

Secondary healthcare facilities (SHCF)

Primary healthcare clinics (PHCC)

90%

88
87
86

85%

83
82

80%
75%

79

79

76
74

74

73
72

70%

69

95% 75% 93% 78% 91% 83% 90% 85% 91% 81% 90% 83%

69

68
66

65%
60%

60

60

50%
45%

q 1-2

q 3-4

q 1-2

q 3-4

q 1-2

q 3-4

2008 2009 2010 2011 2012

2010

2011

Follow up intervals since ART initiation

Scale-up

Post scale-up period

Figure 9

2012

Figure 10

4.3 Improved retention in care (RIC)
Retaining people on lifelong treatment for HIV is challenging in most settings around the world, and Shiselweni is no
exception. Retention in Care (PHCC and SHCF combined) has
consistently improved over time at every follow-up interval
assessed, as shown in figure 9.
Gains in retention were also seen for HIV patients with thehighest risk of death (those with CD4 counts ≤ 50), indicating a higher quality of care in later years : the combined riskof death and loss-to-follow up decreased by 14 % (20092010) and 42 % (2011-2012) compared to pre-scale-up years(2007-2008). Easier patient access to HIV/ TB care (i.e. closer
to patients’ homes), laboratory services integrated into
PHCC, enhanced patient support through a comprehensive
counselling package, and increased community awarenessabout the importance of adherence to a long-term treatment were all key to gradually improve ART retention acrossthe entire region.

5 RIC is followed up per cohort. The years shown in figure 9 correspond to the years of beginningof treatment for the different cohorts.

20

Despite the shifting of certain tasks to new health cadresand the inclusion of lay people (including PLWHA) in providing HIV care, retention of ART patients at the PHCC level
was higher than at SHCF, at least in the early phase after
initiation when this indicator was assessed (see figure 10).
The fact that PHCC’s typically follow fewer patients than thebusier SHCF’s, and can therefore provide more individualised care, may help explain this trend.
However, these data also show that 6-month retention rates
also improved at SHCF in 2011-2012, reaching over 80 %. This
may reflect another benefit of decentralising HIV/ TB services : relieving pressure on the few centralised and specialised SHCF, by distributing case load more uniformly over theregion. Decongestion of SHCF, in turn, allowed clinicians togive more attention to higher-risk patients, including thosewith complications, resulting in better retention. This may
explain why SHCF achieved high 6-month retention rates >80 % only during the post-scale up period (see figure 10).
Better retention in treatment, together with increased ART
coverage and better outreach to less sick HIV-infected people, represent important successes of the HIV/ TB decentralisation programme in the Shiselweni region.

Making a Difference – Decentralisation of HIV/ TB Care in Shiselweni Region of Swaziland

Summary Evaluation Report – December 2013

Annual TB Incidence &Estimated ART Coverage in Shiselweni

TB Treatment Initiations at PHCC
2008-20132007-2013
New TB casenotification /100,000 pop.
% ART coverage

1400

1303

1200
1078

2565

2249

827

80%

45%

400

55% 54% 54%

1500

1337
446

33%

1000
500

20%
2007 2008 2009 2010 2011 2012 2013

Figure 11

1822

86%

626

600

0

2819

2000

800

200

3000
2500

1109

1000

Number TB caseregistrationsin Shiselweni% TB initiationsat PHCC

0

961

0%

4%

2008

2009

2010

2011

2012

2013

Post scale-up period

Figure 12

4.4 TB spread & shiftof treatment initiation to PHCC
In parallel to the devastating spread of HIV/AIDS in
Swaziland, the TB burden has also increased, peaking in2009 with 1,303 TB new cases per 100,000 people peryear—the highest incidence of any region in Swaziland(see figure 11). Additionally, in Shiselweni HIV/ TB care wasdecentralised and ART coverage increased significantly,
from about 20 % in 2007 to 80 % in 2012. These factors, evenalongside enhanced TB case finding throughout the country
starting in 2009, led to a rapid decline of TB incidence ; thedownward trend was fastest in the Shiselweni region, andreached 446 new cases per 100,000 people per year in 2013.
Huge efforts in 2009 and 2010 to decentralise TB services—in particular, nurse-led TB treatment initiation and follow-up at PHCC—led to a major shift in TB care, as shown infigure 12 : while in 2009 only 4 % of TB treatment initiations
occurred at PHCC, this number increased to 55 % in 2011.

Summary Evaluation Report – December 2013

Making a Difference – Decentralisation of HIV/ TB Care in Shiselweni Region of Swaziland

21

4.5 Improved treatment outcomesfor DS-TB patients
In general, the programme showed a steady and significant
trend towards improved TB treatment outcomes both forbacteriologically confirmed and unconfirmed DS-TB cases
at PHCC and SHCF combined, with cure rates 6 increasingfrom 67 % in 2009 to 79 % in 2012 (see figure 13).

6 A cured patient is a patient that was initially smear-positive, completed the treatment, and wassmear-negative in the last month of treatment and on at least one previous occasion.
(WHO definition, http ://www.who.int/tb/publications/global_report/2007/table_5/en/index1.html)

However, TB is the main cause of mortality in HIV-infectedindividuals in most settings ; not surprisingly, in 2012 TB
mortality in Shiselweni remained high (15 %), with 83 %of these deaths occurring in HIV co-infected patients.
Therefore, despite the overall positive trend in TB curerates, the treatment success rate is still below the WHOtarget of 85 %. Achieving the WHO target in this high HIV
prevalence setting will require that TB co-infected patientsenter treatment earlier, when better outcomes can more
readily be achieved.

Figure 1385%80%

Drug-Sensitive Tuberculosis (DS-TB) Cure Rates
2009-2012
77%

75%
70%
65%

79%
78%

74%
72%

71%
70%

67%
65%

72%
68%

65%

60%
50%
40%

New confirmed PTB
New unconfirmed PTB
New extra-PTB% DS-TB
patients cured

30%
20%
10%
0%

22

2009

2010
Scale-up

Making a Difference – Decentralisation of HIV/ TB Care in Shiselweni Region of Swaziland

2011

2012

Post scale-up period
Summary Evaluation Report – December 2013

4.6 Improved accessto DR-TB treatment
Follow-up of DR-TB patients was first decentralised from national to regional
level at SHCF, then in a second step to PHCC (2008), and, finally, to community
level for patients living in remote areas. Members of the community, who became the community treatment supporters (CTS), received training about DR-TB
treatment during the intensive and follow-up phases, including implementationof daily DOTS (directly observed treatment, short-course) and administration of
intra-muscular injections. Through this approach, combined with active defaulter
tracing, the DR-TB treatment outcomes slightly improved since the beginning of
the programme. The success rates (treatment completed and patient cured) wereconsistently higher that the national ones (MoH 2012). The proportion of patients
lost to follow-up (LTFU) during treatment decreased from 10 % in 2008 to 2 % in2012, as shown in figure 14.
An in-depth comparison of adverse treatment outcomes (LTFU/death/failure)in patients followed at outpatient departments by health professionals versus
those followed at the community level by CTS showed equivalent treatment
outcomes. This finding suggests that daily support for DR-TB care through the
CTS probably improved treatment adherence for patients living in most remotelocations, who usually cannot access daily DR-TB at health facility level and thus
are at the highest risk of defaulting and death.

Figure 1480%

Drug-Resistant Tuberculosis (DR-TB)
24-Month Regimen Outcomes
71%

70%
63%

60%
50%
40%

% Success (completed & cured)

DR-TB cases

30

66%

65%

100

135

140

30%
20%
10%

2008

2009

10%
% Defaulter

5%

2010

8%

0%

Summary Evaluation Report – December 2013

2011

Making a Difference – Decentralisation of HIV/ TB Care in Shiselweni Region of Swaziland

2%

23

9000

Numbers of HIV Proxy Conditions (Regardless of HIV Status)
Diagnosed at Outpatient Departments

8000

2007-2012 in SHCF and PHCC combined
7401

7000
6000
5000

Herpes Zoster
Persistent diarrhoea
TB suspect
Malnutrition

6853

6732

6171

AIDS

5905
5201

5414

4665
3998

4000

3401

3135

3000

2619

2000
1000

2719

2278

2120

1585
1439
1097

3217

1417

1478
1201

1305

1483
1013
727

0

Figure 15

1483
773
700
340

2007 2008 2009 2010 2011 2012
4.7 Reduced incidenceof opportunistic Infections
It is well-known that ART prolongs life and prevents or
mitigates opportunistic infections (OI’s) and other HIVassociated conditions in PLWHA (Hogg et al, 2008). In ahigh HIV prevalence context such as Shiselweni, increasing ART coverage is therefore expected to reduce overall
HIV-related morbidity.
As shown in figure 15, the absolute burden of typical HIVassociated conditions diagnosed (regardless of patients’HIV status) at all outpatient departments across theregion followed a two-phase pattern. The annual numberof new diagnoses increased during the HIV/ TB programmescale-up period (2009-2010), due to expanded patient
access to quality care, including nurses trained in HIV/ TB
and in diagnosing OI’s. Subsequently, after the scale-up
period (2011-2012), the number decreased dramatically.
For instance, diagnoses of AIDS and malnutrition (which
in Swaziland is usually related to HIV) decreased 10- and7-fold, respectively, between 2009 and 2012 (MoH routinedata). Consequently, the rapid ART scale-up and attainmentof high treatment coverage alleviated the burden on thehealth care system.

24

Making a Difference – Decentralisation of HIV/ TB Care in Shiselweni Region of Swaziland

Summary Evaluation Report – December 2013

Estimated Crude Mortality Rate (Inpatient & Outpatient)in Shiselweni Region

461

446

456
327

Death incidence per
100,000 population

216

2008

Figure 16

2009

2010

2011

2012

4.8 Decreased crude

mortality rate
From the time HIV/AIDS hit Swaziland in the early 1990’s,
life expectancy declined steadily. In Shiselweni, crude
mortality rate seen in inpatient and outpatient departments
stabilized by 2008-2009 and then declined 2-fold in 20102012 (see figure 16). We presume that the high level of ART
coverage and the improvement in quality of care are behind
this observation (MoH routine data).

Summary Evaluation Report – December 2013

Making a Difference – Decentralisation of HIV/ TB Care in Shiselweni Region of Swaziland

25

26

Making a Difference – Decentralisation of HIV/ TB Care in Shiselweni Region of Swaziland

Summary Evaluation Report – December 2013

5

PERCEPTION & ACCEPTABILITY
OF DECENTRALISED HIV/ TB CARE
5.1 Perceptions of the model& its impact on patient care
The perception study was conducted through individual and group interviews, aswell as focus groups discussions. Respondents included health workers, patients,
community leaders, MoH, MSF staff and other national and international actors.
The results of this study identified some clear shifts in the perception andacceptability of various components of the programme over its first five years.
These are summarised below.
Decentralisation was widely recognised as a success in significantly increasing
access to HIV and TB services, since distance and costs for travel and lost work
time are major barriers to care. For these reasons, the availability of services at
the PHCC level was highly appreciated by both staff and beneficiaries. However,people living in very remote areas still face difficulties accessing care. Greater
accessibility, in turn, is credited with increased coverage for early diagnosis andtreatment, improved treatment outcomes and better retention in care.
There is general agreement that decentralisation of services has had a positive
impact on the quality of care. Quality is perceived as very good at PHCC, but
as more mixed at centralised facilities. In addition, waiting times at clinics areshorter than they were at central facilities before decentralisation. Overall acceptability of HIV/ TB services at PHCC level is therefore very high.
Task-shifting is now widely accepted as feasible and indispensable to thedecentralisation of HIV/ TB care in Swaziland, given the country’s limited humanresources for health. Although there was initial resistance, it was overcome overtime by demonstrations of feasibility and impact, and by the provision of training
to health workers taking on new roles. On the latter point, the combination of formal staff training with mentoring and supervision was considered effective andwas highly appreciated by participants. Government-certified training courses
further increased acceptance and are seen as necessary for the integration of
future cadres.
Advocacy by MSF together with other implementing partners was also instrumental in fostering acceptance of task-shifting. This advocacy (described in
section 3.3) led, among other outcomes, to the development of the National TaskShifting Framework (NTSF). This crucial policy document defines new roles andtasks for health cadres, as practiced under the task-shifting model.
Integration of HIV/ TB care into primary health care has increased the level of privacy for patients, compared with central health facilities that provide HIV care atdedicated ART clinics—which segregate, and thereby label, HIV-positive patients.

<
An HIV positive patient on ART from
Mnyatsini village in the Shiselweni region.

Summary Evaluation Report – December 2013

The small user fees charged by PHCC (5 Emalangeni, equivalent to 0.30 Euros)
were not seen as an obstacle to seeking care, although both higher fees at thecentral level and charges for non-HIV/ TB care and for medicines at private clinics, seemed to deter some patients. In choosing a health facility where they willseek care, patients considered convenience (shorter distance and lower travelcost) as the number one factor. A smaller number of patients cited fear of being
recognised by community members at the local clinic, or the perception that better care was available elsewhere, as reasons for selecting a more distant facility.

Making a Difference – Decentralisation of HIV/ TB Care in Shiselweni Region of Swaziland27

5.2 Increased motivation for staff
Medical professionals at the central level noted a decreased workload comparedto earlier days of providing ART and TB treatment. Nurses at the clinics varied intheir perceptions of changes to their workload, while other staff members perceived a significant decrease in overtime following decentralisation.
All cadres of health workers stated that they felt empowered by the successful
outcomes of their work after decentralisation, and reported very high motivation
and work satisfaction.
Clinic staff expressed confidence in their skill level, as did their supervisors from
MoH and MSF, based on seeing the successful health outcomes for patients.
The skills of former lay cadres were valued by their professional colleagues,
who viewed them as specialists in their area—for example, expert patients who
work as counsellors were described as being crucial in this role. Involving PLWHA
in health care provision was seen as key to increasing the acceptability of HIV
testing and treatment, improving adherence and boosting patient empowerment.
Since they are viewed as role models in the community, their presence in theclinic was also perceived as encouraging the disclosure of HIV or TB status, which
in turn helps reduce stigma.
Interdisciplinary team relationships after decentralisation, integration of HIV/ TB
services and task-shifting, were largely perceived as positive, especially at theclinic level.
Staff members also highlighted improved protection of clinic workers from therisk of HIV or TB infection—through implementing better infection control measures and making post-exposure treatment available at the workplace, as provided by MSF—as very important to their job satisfaction.

5.3 Acceptance of community activities
Community-based activities were viewed as another strength of the Shiselweni
model. Engaging through training, consultation and collaboration with village
chiefs and other community leaders, traditional healers, religious leaders andrural health motivators was perceived as a very powerful strategy for promoting
positive health behaviours and reducing stigma. A traditional healer taking ARVs
and who disclosed his status publicly on World AIDS Day was mentioned in thiscontext as a positive example.
MoH officials and other national and international actors expressed appreciation
for the integration of TB into MSF community activities, a step they viewed as dis-tinct from treatment practice by other organisations.

28

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Summary Evaluation Report – December 2013

5.4 Speed of implementation

versus engagement with authorities
Study respondents expressed a range of opinions about MSF’s speed of implementing new programme activities and about its hands-on approach. On
one side, the rapid roll-out of decentralisation was seen as greatly benefiting
patients and contributing to the demonstration that new strategies and higher standards of care are feasible in the Shiselweni setting. Many participants
concluded that less would have been achieved if MSF had not put itself “in thedriver’s seat.” On the other hand, MSF was initially perceived by MoH as using an
emergency approach that was inappropriate for chronic disease control.
This latter perception, and the lack of joint planning at the regional level, contributed to initial resistance to the MSF project and delayed the development of amore productive early collaboration between MoH and MSF. However, it was also
noted that a positive shift in MSF’s collaboration with MoH towards increased
dialogue and engagement subsequently ushered in a more fruitful partnership.
Part of this engagement involved demonstrating the feasibility of proposed
innovations by piloting these approaches before widescale implementation and,in parallel, encouraging operational research to improve them and assess theiroutcomes ; the impressive results obtained helped make MoH more receptive
to MSF’s proposed strategies. Dialogue with national counterparts and otherstakeholders was also seen as a very powerful tool in identifying priorities andcommunicating the lessons learned. Thus, MSF was a catalyst for change not
only in the field but at a policy level.

Summary Evaluation Report – December 2013

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29

6

PERCEPTION OF REMAINING CHALLENGES

Despite an overall increase in the uptake of testing and treatment services in
the region, coverage of these services among men and youths is still viewed as
insufficient. Low rates of testing, especially among men, also pose a challenge toimproved prevention, as does inconsistent use of condoms by all groups surveyed. Other remaining challenges in the region include unsatisfactory paediatrictreatment coverage and outcomes in the region, as well as proper monitoring anddocumentation of PMTCT programmes.

6.1 Stigma
While stigma related to HIV/ TB is widely seen to have decreased significantly inrecent years—a change attributed to both improved knowledge and availabilityof ART—it is still considered a major barrier to disclosure of HIV status and to the
management of HIV/ TB care.
Disclosure is generally seen as a necessary determinant of treatment adherence
and well-being of HIV-positive people. MSF expert patients typically described
their disclosure experience as being relieved of a burden, and as the beginningof a new, more confident life. They also recognised that reduction of fear andstigma in the community is linked to disclosure. Unfortunately, examples of public disclosure are still extremely few in the region, and mostly limited to female
community members.
While different gender norms and use of maternity care make it easier to reach
women at health facilities, cultural expectations of men discourage early
health-seeking behaviour. This is often compounded by men’s stronger fear of
HIV-related stigmatisation and by perceptions that clinics are not sufficiently
male-friendly. Men and youths in Swaziland, as in many other parts of the world,
are seen as hard-to-reach groups.
One potentially big opportunity for reducing stigma arises from the fact that
community leaders (chiefs, traditional healers, pastors, etc.) are highly respected
and influential in the rural Swazi society. Involving them is therefore perceived
as an important strategy for enhancing acceptance of services and decreasing
HIV- and TB-related stigma at the community level. Disclosure among community
leaders or other influential people can be an especially powerful tool in the stricthierarchical society of Swaziland.

6.2 Continuity
Despite the fact that some important pre-conditions for thecontinuity of the Shiselweni
programme are met—including
political will to sustain the basic
decentralised HIV/ TB care model,
the capacity-building of staff, andeffective laboratory support—
there is concern that the quality ofcare could deteriorate and somesystems could collapse once MSF’s
support ends. The major barrier tocontinuity is seen as lack of funding, mostly for human resources
but also for laboratory reagents,
sample transport, drug supply
and supervision, all of which arepresently supported by MSF. MSF’s
ongoing leadership in the regional
programme implementation is perceived as another barrier to greater
MoH ownership.

>
People living with HIV during a
Support Group meeting at
KaPhunga, in the Shiselweni region.

30

Making a Difference – Decentralisation of HIV/ TB Care in Shiselweni Region of Swaziland

Summary Evaluation Report – December 2013

Summary Evaluation Report – December 2013

Making a Difference – Decentralisation of HIV/ TB Care in Shiselweni Region of Swaziland

31

32

Making a Difference – Decentralisation of HIV/ TB Care in Shiselweni Region of Swaziland

Summary Evaluation Report – December 2013

7

COST EFFECTIVENESS

The main goal of this cost-effectiveness evaluation was to compare the decentralised approach to a centralised one from a service provider perspective. To
make this comparison, the incremental cost-effectiveness ratio (ICER) of PHCC
versus SHCF was calculated, and then, following WHO’s criteria, compared to
Swaziland’s GDP (WHO 2013).
By this measure, the decentralised ART programme at PHCC in Nhlangano healthzone is more cost-effective than the ART programme at SHCF. This conclusion isbased on calculating an ICER of US$ 652 per life-year saved in PHCC versus SHCF,
a figure which is much less than the GDP per capita in Swaziland (US$ 5,300).

Opportunities for cost-saving
The cost analysis identified some opportunities for savings. Annual treatment
cost (for service providers) per ART patient was slightly higher at PHCC (US$ 311)
than at SHCF (US$ 233). This difference is mainly due to higher human resource
costs, which are roughly 2-fold higher in the clinics compared to SHCF’s, in termsof both supervision staff and direct staff costs for consultations with patients.
This finding is explained by comparing the ratio of consultations to staff members at the PHCC versus SHCF levels, which shows that the higher costs for PHCC
are due to the lower number of patients who come to the clinic each day rather
than to staff spending too much time with patients. Therefore, the same level ofcare could be reached with more optimised human resources.
Laboratory monitoring costs are nearly identical in primary and secondary facilities, despite the fact that the technologies used and the level of cadres performing the tests are very different. Transport costs are higher at PHCC, but thedifference is not significant.
Optimising the use of human resources for health in the PHCC (direct staff andsupervision) is therefore a high priority for increasing the efficiency of ART programmes in Shiselweni.

<
MSF Patient Support Education andCounselling (PSEC) Community Supervisor,
Sylvia Khuzwayo with Community expert
patient, Busi Gumbi and HIV patient.

Summary Evaluation Report – December 2013

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33

8

RECOMMENDATIONS

8.1 At project level
Address HIV/ TB-related stigma, focusing on
hard-to-reach groups.
• Expand inclusion of community leaders in planning and implementing community-based activities so that their local
knowledge can enhance programmes and their influence
on community members can help reduce stigma and foster
acceptance of services.
• Encourage disclosure as a vehicle for reduced stigma
and discrimination.
• Strengthen and adapt services for men in their local
environment and workplaces, for example by using malestaff, male expert patients and male health workers, andby piloting more convenient opening hours for clinics(evenings, weekends).
• Strengthen youth-friendly (outreach) services.
• When piloting new male/youth-friendly strategies, solicit
regular feedback from target groups on their perceptions
and acceptance of these strategies.
Increase cost-effectiveness of the decentralisation
programme by rationalising human resources costs atthe clinics.

8.2

Implement a community-based ARV medicines
distribution model.
• Establish more ARV distribution points that are closer toremote communities. Schools and community centres could
be used for this purpose.
• Pilot community ART groups, for example, small groups inremote areas.
• When piloting different community-based ARV distribution
models, solicit regular feedback from target groups on theirperceptions and acceptance of these approaches.
Strengthen MSF support to the regional and secondary
health care facilities in Shiselweni.
• Strengthen support to the regional health authorities in termsof their management capacity and supervision of PHCC’s.
• Strengthen support to the SHCF’s for clinical ART management and for task-shifting and integration of TB andHIV services.

At country level
Replicate the best practice components of HIV/ TB decentralisation in Shiselweni at the national level.
• Introduce nurse-led ART and TB at all health facilities,
along with well-organised task-shifting to new cadres.
• Introduce strong patient support, education and counselling by expert patients.
• Implement full integration of HIV and TB treatment,
including MDR-TB, into general health care.
• Build strong community components within programmes, ensuring productive linkage between healthfacilities and communities.
• Decentralise laboratory services by establishing mini-laboratories at all clinics and implementing a sample
transportation system to reference laboratories.
Address policy issues• Advocate for full implementation of the National TaskShifting Framework.

Improve continuity of the current Shiselweni
HIV/ TB programme.
• Ensure systematic joint programme planning, monitoringand supervision activities with the MoH, to foster MoH ownership and long-term preparation for eventual handover ofprogramme components.
• Explore alternative funding possibilities and identify
implementing agencies to take over components currently
supported by MSF.
• To optimise staffing levels, systematically assess theworkload at individual clinics relative to international andnational standards.

34

Making a Difference – Decentralisation of HIV/ TB Care in Shiselweni Region of Swaziland

Summary Evaluation Report – December 2013

FUTURE PERSPECTIVES : INCORPORATING“TREATMENT AS PREVENTION” STRATEGIES

9

A crucial next step in the evolution of the Shiselweni decentralised programme
model is to incorporate HIV “treatment as prevention” strategies into its operations, so that the high rate of new infections can be curbed and the HIV/AIDS and
TB epidemics slowed.
As part of its ongoing work in decentralising HIV and TB testing and care to thecommunity level, MSF, in collaboration with Swaziland National AIDS Programme(SNAP), proposes to pilot various test & treat strategies—first for HIV-positive
pregnant women (PMTCT B+ strategy) and subsequently for HIV-positive adults.
These activities aim to contribute to the reduction of HIV-and TB-related mortality, morbidity and incidence in the region while demonstrating acceptability andfeasibility of these strategies.
The main components of the proposed programme are :• Reinforcing HIV testing and retention in treatment through provider-initiatedand community-based HIV testing, reinforcement of pre-ART care and community-based self-management of ART.
• Piloting PMTCT B+ (test & treat for all HIV-positive pregnant women) in the Nhlangano Health Zone, through the Mother and Child Health (MCH) services of the
Public Health Unit (PHU) and Maternity of the Nhlangano Health Centre and the
MCH services of the 7 PHCC’s (pilot to run from early 2013 to 2016).
• Demonstrating acceptability & feasibility of Early Access to ARV for Adults (EAAA)
strategy for HIV-infected adults in the Nhlangano Health Zone (pilot to run from2014 to 2016).
This proposed programme aligns with the Swaziland Treatment as Prevention
National Framework, which supports evidence-based interventions through a
National Research Platform that coordinates operational research on Treatment
as Prevention. If successful and adopted by the Swaziland National AIDS Programme, PMTCT B+ (and later EAAA) can then gradually be rolled out to the othertwo health zones in Shiselweni and the rest of the country.
Detailed implementation plans for the two pilots will be developed throughdiscussion with the relevant departments in the MoH, including SNAP and the
Sexual and Reproductive Health Unit (SRHU). All pilot activities will be carried out
under normal programmatic conditions where possible. During the 4-year periodof the pilot studies, MSF commits to provide all required resources (diagnostic tests, ARV medicines and additional human resources) beyond the ongoing
HIV/ TB services.
Accompanying qualitative and quantitative research will be carried out by an

MSF research team in close collaboration with SNAP and the SRHU (for PMTCTB+). This research will include ethnographic and epidemiological studies toaddress feasibility, acceptability and effectiveness of the different pilot interventions. The research will also include a costing study with marginal analysis
for each additional programme component and resource relative to standard
programmatic conditions.

>
A Drug sensitive tuberculosis (DS-TB)
patient from Nsalitje in Shiselweni.

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Summary Evaluation Report – December 2013

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ACKNOWLEDGEMENTS

We would like to thank the team from the MSF-Vienna Unit for putting together the five reportssummarised in this capitalisation report, and Mzia Turashvili for leading the process.
We would also like to thank all patients, community members, health staff, and representativesof MoH at the national and regional levels, MSF, HIV/ TB partner agencies and civil society
organisations who graciously gave their time for interviews and openly shared their thoughts, ideas
and recommendations.
Our gratitude goes to the Mbabane and Nhlangano MSF-CH teams for their support, interestand fruitful collaboration, and to the interpreters and the interview transcription team for theirimportant contribution to this study.
Finally, a very special thank you to Patricia Kahn at MSF-USA for editing the report and to Patricia
Armada and Anaïs Coulon for making it look beautiful.

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11

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Impressum
Photos Giorgos Moutafis
Graphics Patricia Armada & Anaïs Coulon
Printing Ast & Fischer AG© Médecins Sans Frontières – Switzerland 2014<
Patients waiting at the Zombedze clinic,
where MSF has decentralised TB andHIV services, in the Shiselweni region.

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www.msf.ch40

Médecins Sans Frontières
Rue de Lausanne 78, Case postale 116, 1211 Genève 21
T + 41 (0)22 849 84 84 – F + 41 (0)22 849 84 88 – office-gva@geneva.msf.org

Making a Difference – Decentralisation of HIV/ TB Care in Shiselweni Region of Swaziland

Summary Evaluation Report – December 2013