Photo © Jonathan Heyer

Fighting a dual epidemic
Treating TB in a high HIV prevalence setting in rural Swaziland
January 2008 – June 2010

Swazi people
fighting HIV & TB together in Shiselweni

Acknowledgements
The MSF supported programme in Shiselweni would not have achieved the successes outlined in this report without
the tireless commitment of the nurses, expert clients, laboratory staff, pharmacy staff and doctors working throughout
the region.
Most importantly, thanks are due to the many people with TB and living with HIV who have motivated their friends
and family members to seek care and treatment early, and who continue to provide a positive role model forthousands of Swazis.

Médecins Sans Frontières/Doctors Without Borders (Switzerland)
Plot 392, Lukhalo Street
Dalriach East
MbabaneTel office: +268 404 83 07
Fax office: +268 404 78 84
Cell: +268 661 35 37
www.msf.ch
www.msf.org.za/swaziland/

Cover photo: Clinic nurses work hand in hand with expert clients in dispensing antiretroviral drugs to patients
Back cover photo: For patients who adhere to their treatment, there is hope and the chance of a positive life
Design and artwork: Twenty 3 Crows Ltd 01848 200331

1

Table of contents
2

Executive summary

4

Introduction

7

Programme services and outcomes
Tuberculosis services
Intensified case finding
Improved laboratory capacity
Tuberculosis outcomesDrug-resistant tuberculosis
Detection of patients with drug-resistant tuberculosis
Multidrug-resistant tuberculosis treatment outcomesA 'one-stop service' for TB and HIV care
Psychosocial support among patients and in the community
Infection control
HIV testing and counselling
Antiretroviral therapy
Isoniazid Preventive Treatment
Co-trimoxazole

19

Strengthening the healthcare system to provide TB and HIV care
Task shifting
Improving health system infrastructure
Staff health
Mobile teams
Improving laboratory services
Decentralising sample collection

22

Future challenges
Improving human resources management
Integrated HIV/TB care at primary care level
Reinforcing drug supply and management
Data management
Long term adherence to ART and TB treatment
Drug-resistant tuberculosis
Building national healthcare capacity

25

Conclusion and recommendations

2

Executive summary
In Swaziland a dual epidemic of tuberculosis (TB) andHIV is threatening to wipe out entire generations. The
country has the highest HIV prevalence in the worldamong adults, coupled with one of the highest
incidence rates of TB. The great majority of TB
patients are co-infected with HIV, and TB is the leading
cause of mortality among HIV-positive patients. To add
to this, a new challenge is emerging in the form of
drug-resistant tuberculosis (DR-TB). The dual epidemic
is taking a deadly toll on the people of Swaziland,
whose life expectancy has halved over the past 20
years – from 60 to 31 years. People are dying in large
numbers, children are being made orphans and theworkforce is declining. It is a health emergency ofhuge proportions. Tackling this crisis is being
hindered by an acute shortage of medical staff, by an
inadequate diagnostic capacity and by patients failingto complete their treatment, often because of theprohibitive cost of making long and frequent journeys
to distant health facilities.
Médecins Sans Frontières (MSF) and the Ministry of
Health (MoH) of Swaziland are working together tofight the co-epidemic. In Shiselweni, the country's
poorest and most remote region, they have adopted adecentralised, integrated and patient-centred
approach.
Despite numerous challenges, the joint programme
has had a considerable impact in the past two-and-ahalf years. Twenty-one sites throughout Shiselweni
region have been developed as fully integrated 'onestop services' for HIV and TB care, offering treatment
initiation and follow-up at primary care clinics. DR-TB
care has been decentralised to the region's three main
health facilities, with further decentralisation to clinics
and communities for all DR-TB patients on injectionsin the intensive phase of treatment. More generally,outreach teams are extending the provision of HIV and
TB services into outlying communities.

The result is that increased numbers of patients arebeing diagnosed and initiated on treatment earlier,fewer patients are defaulting from their treatment, andtreatment outcomes have improved significantly. The
number of people tested for HIV each month has morethan tripled, the number of people initiated on
antiretroviral therapy (ART) has doubled, and TB
outcomes have seen a marked improvement.
In a national health crisis where financial and humanresources are so limited, much of the success of thismodel of care delivery lies in task shifting. By using
trained and supervised lower cadre health workers toprovide more widespread access to HIV and TB care,
MSF and the MoH have succeeded in keeping carewithin the community and tapping into the growing
resource of expert clients with direct experience andknowledge of HIV, TB and related issues.
Decentralising services has also dramatically improved
patients' access to care. Instead of having to makelong, repetitive and expensive journeys to the region's
health facilities, many patients can now access HIV
and TB services close to their homes. Giving DR-TB
patients the option to receive injections and oral drugs
at home during the intensive phase of treatment has
been another major step forward in adapting care tomeet patients' needs and support treatment adherence.
Improved infection control measures have madehealthcare environments safer for both staff andpatients. Intensive case finding among HIV patients at
all clinics is also improving infection control in thecommunity by identifying TB patients and startingthem on treatment earlier. Psychosocial support isincreasing awareness of TB and HIV among patientsand the wider community, contributing to more people
coming forward for testing and treatment, better
retention in care and a reduced risk of infection
transmission within the community.

3

with HIV in need of ART, and with the growing number
of TB and DR-TB patients. Well-functioning,
standardised systems of drug management and data
management must also be introduced and maintained.
Introducing these measures should be a top priority.
The scale of the co-epidemic in Swaziland demands
urgent political commitment translated into immediate
action.

The challenge now is to build on these successes anddevelop fully MOH-managed decentralised HIV and TB
services that overcome the geographical and financial
barriers to care that many patients still face. Task
shifting must be expanded to allow nurse initiation of
ART and to manage the growing number of people
with HIV in need of treatment. Laboratory capacity
must be further strengthened and expanded in eachclinic, to cope with the projected increase in people

Médecins Sans Frontières/Ministry of Health of Swaziland joint decentralisation project of integrated HIV/TB services
in Shiselweni region. Total population: 208,454.

+

Phunga Clinic+

Magubheleni Clinic

Kamfishane Clinic++

Nkwene Clinic(HIV/TB integrated pilot project)

Shiselweni Region

PHU++ Hlatikhulu
Hlatikhulu Hospital+Gege Clinic+

Mashobeni Clinic

Nhletleni Clinic

New Heaven Clinic

Health Facilities (HIV/TB integrated pilot project) Dwaleni Clinic ++ Ntshanini Clinic+++ Hospital
HholomiNATICC VCT Centre +++ PHUClinic Nhlangano+++SOS
Philani Clinic Nhlangano
SileleMahlandle Clinic+ Health Centre
Nhlangano Health Centre+ JCI Mphelandzaba+ Clinic(HIV/TB integrated pilot project)++
Mhlosheni Clinic
MSF Switzerland+
Htuthi Clinic
Zombodze Clinic
+
+
Roads
Matsanjeni
Our Lady of Sorrows
Lavumisa Clinic
Paved
Health Centre+
South Africa
UnpavedPhoto © Aymeric Péguillan/MSF

People learn about tuberculosis at a community event in Mtsambama Thinkhundla on World TB Day 2008

Introduction
Swaziland (population 1.018 million) is a small, mountainous country
landlocked by South Africa and Mozambique, and one of three
monarchies in Africa. Despite its status as one of the 'wealthier'countries in sub-Saharan Africa, the kingdom is rated 142nd on thehuman development index (UNDP 2009), and an estimated 81% of the
population live on less than US$2 per day. The country's wealth lies inagriculture (sugar cane) and forestry resources (for paper pulp);
however the majority of export commodities are manufacturing products
sold on the South African and US markets, such as miscellaneousedibles (mainly soft-drink concentrates) and textile products. The
economy is highly dependent on that of South Africa. Since the end of
the 1990s, economic growth has decreased to below 0.4% in 20091,2,3.

Currently, Swaziland is in the grip of a dual health emergency. The
country has the highest HIV prevalence worldwide among adults aged
15-49 years (26.1%)4 and one of the highest tuberculosis (TB) incidence
rates (1,198 TB cases/100,000/year)5. TB is the leading killer amongpeople living with HIV, and in Swaziland more than 83% of TB patientsare co-infected with HIV6. The co-epidemic has contributed substantiallyto a halving of life expectancy within two decades – from 60 years in the
1990s to 31 in 20077. The high mortality due to HIV and TB is a tragedy
that is affecting communities and the economy: parents are dying,children are becoming orphans, and the workforce is slowly
disappearing.

1 National Population and Housing Census, Swaziland 2007
2 UNDP Human Development Report, 2009. Available at http://www.undp.org/hdr
3 Central Bank of Swaziland, 2009
4 UNAIDS http://www.unaids.org/en/CountryResponses/Countries/swaziland.asp

5 WHO Swaziland TB Country Profile, estimates of epidemiological burden, 2007
6 UNDP Human Development Report 2009
7 UNAIDS Swaziland Country Progress report 2010

5

In 1999, the King of Swaziland, Mswati III, declared HIV as a national
emergency. Since then, a National Emergency Response Council on
HIV and AIDS (NERCHA) has been established and, in September
2009, the Ministry of Health (MoH) took an important step forward in HIV
management through revision of its national antiretroviral therapy (ART)guidelines to increase the CD4 cut-off point for treatment initiation from<200/mm3 to <350/mm3. Given the large – and growing – number ofpeople living with HIV, urgent measures are necessary to address the
HIV epidemic and get more patients on antiretroviral therapy. In 2009,
an estimated 185,803 people were already living with HIV, and thatfigure is projected to rise to 216,735 by 2015. Although a decrease in
the number of new annual HIV infections is forecast (from 12,281 in2009 to 11,381 in 2015), AIDS-related deaths are also expected to risein the same period, from 7,114 to 8,393. Women are disproportionately
affected (with 30% prevalence, compared with 20% among men), while
HIV prevalence by age peaks earlier among women than men, at 25-29
years and 35-39 years respectively8. The rate of infection among
pregnant mothers has risen ten-fold, from 4% in 1992 to 42% in 20089.
The outlook for TB is equally bleak. TB remains the leading cause of
mortality among HIV-positive patients in Swaziland. The TB notification

rate has increased steadily (from 119 notified new smear-positive
cases per 100,000 population in 2001 to 242 notified new smearpositive cases in 2007). Management of drug resistant TB (DR-TB) isa growing challenge – results from a national drug resistance survey
show multidrug-resistant TB (MDR-TB) prevalence rates of 7.7%
among new TB cases and 33.9% in previously treated cases10, farhigher than the World Health Organization's (WHO) 2008 estimates of
MDR-TB prevalence (0.9% among new cases and 9.1% among
previously treated cases)11. HIV co-infection was significantly
associated with MDR-TB.
In 2006, the then Prime Minister Themba Dlamini made an urgent
request for external help to fight the HIV and TB crisis sweeping thecountry. MSF launched a preliminary assessment in 2007 to identify
areas for support, and found chronic staff shortages, poor-quality careprovision, no integration of HIV/TB services, inadequate capacity toprovide HIV care at primary clinics and a largely centralised service
for the treatment of TB and DR-TB. Given the high costs of transport
to health facilities providing HIV and TB services, care was, inpractice, inaccessible for the majority of Swazis living below thepoverty line.

Tackling Swaziland's human resource crisis
Swaziland's human resource crisis is one of the biggest obstacles to tackling the HIV/TB co-epidemic. In 2004, 44% of posts for doctors, 19% of
posts for nurses and 17% of nursing assistant posts were unfilled13. There is no medical school in Swaziland and, of the approximately 170 nurses
and midwives who graduate each year, a large proportion emigrate. Staff attrition to HIV is high – at around 4% each year – and it is also high to
TB. Currently, the Swazi health system is benefiting from an influx of skilled Zimbabwean healthcare workers. However, if the Zimbabwean
economy recovers, many of these workers may repatriate. The staffing crisis is further exacerbated by absences from work due to training courses,
holidays or sick leave – there is often only one nurse on duty for a catchment population of between 7,000 and 16,000. In rural areas, in particular,
the lack of accommodation for health workers makes recruitment and retention of staff very difficult.
Task shifting is well recognised as a way of providing high quality care with limited human resources in contexts such as Swaziland14. Delegatingtasks such as ART initiation, HIV counselling and testing and drug dispensing to lower cadres are key steps to unburdening existing health staff
and increasing access to services essential to providing high quality, patient-oriented TB and HIV care15. Swaziland's Ministry of Health has taken
steps towards shifting responsibilities from doctors to nurses, notably by supporting nurse-driven initiation of TB treatment. Yet the failure todelegate other healthcare responsibilities to lower cadre workers, such as ART initiation to nurses, is still hampering patients' access to care.
Given the scale of the HIV/TB co-epidemic, its continued impact on mortality and the growing demand for treatment, an urgent and rapid expansionof task shifting to encompass a wide range of services must be prioritised.

8 UNAIDS 2010 Swaziland country progress report. Available at http://data.unaids.org/pub/Report/2010/swaziland_2010_country_progress_report_en.pdf
9 HIV Sentinel Surveillance
10 In 2009, a drug sensitivity testing (DST) survey conducted by Swaziland's National TB Control Programme, MSF, Epicentre and Borstel Supranational Reference
Laboratory found 7.7% (95% CI 5.1-11.0) MDR-TB prevalence among new cases and 33.4% (95% CI 28.1-39.1) among previously treated cases.
11 WHO 2010. Multidrug and extensively drug-resistant TB (M/XDR-TB): 2010 Global Report on Surveillance and Response. Available at:
http://whqlibdoc.who.int/publications/2010/9789241599191_eng.pdf
12 National Population and Housing Census, Swaziland, 2007
13 Kober K, Van Damme W. Public sector nurses in Swaziland: can the downturn be reversed? Human Resources for Health 2006, 4:13
14 World Health Organization: Treat train retain. Task shifting: Global recommendations and guidelines. Geneva, 2007. Available:
http://www.who.int/healthsystems/task_shifting/en/. WHO/UNAIDS/PEPFAR: Task Shifting: Global Recommendations and Guidelines, Geneva, 2008. Available online at
http://www.who.int/healthsystems/task_shifting/en/index.html
15 Callaghan M, Ford N, Schneider H. A systematic review of task shifting for HIV treatment and care in Africa. Human Resources for Health 2010. 8:8.

6

Future approaches to TB and HIV management in Swaziland –an international consensus
In October 2009, national, regional and international representatives from governments, academic institutions and non-governmental organisations
came together to define the best operational strategies for the implementation of a decentralised model of care in rural settings affected by high HIV
and TB/DR-TB prevalence. Participants made a series of recommendations on improving TB and HIV care delivery, many of which mirror the modelof care delivery that MSF is implementing in Shiselweni region:• Task shifting is the most appropriate model of care delivery given the scale of the crisis and the limited human resources.
• Addressing the dual epidemic demands a patient-centred approach which prioritises the decentralisation and integration of HIV and TB services.
• Increased resources are necessary to improve the detection and management of DR-TB; widespread drug susceptibility testing and theestablishment of a clinical expert committee to advise on difficult cases are two essential components of a comprehensive model of care.
• Minimum standards for infection control must be introduced.
• Strengthening health information systems is essential to manage the co-epidemic.
• Laboratory resources must be reinforced to cope with existing and growing numbers of patients.
• An uninterrupted supply of quality drugs must be guaranteed.

In November 2007, MSF signed a memorandum of understanding with
the Ministry of Health and Social Welfare to start providing HIV and TB
care (including DR-TB care) throughout Shiselweni region, the poorestand most remote region of Swaziland with a population of approximately
208,45412. The primary objective of the programme was to establish apatient-centred model of care delivery focusing on decentralised TB and
DR-TB care; to establish fully-integrated HIV and TB care; and to
improve infection control. To meet this objective, MSF is supporting MoH
staff at all 21 government health facilities in Shiselweni, comprising 18
primary care clinics, one hospital (in Hlatikulu) and two large healthcentres with inpatient capacity (in Nhlangano and Matsanjeni). Given thedire shortage of health professionals, MSF has sought to scale upprovision of care through task shifting from doctors to nurses and to free
up nurses to perform clinical duties by delegating responsibilities for HIV
testing and counselling to lay community health workers.
This report provides an overview of the services and outcomes during
the first two-and-a-half years of the programme (January 2008 - June2010) and discusses key challenges and priorities for the future.

Photo © MSF• All stakeholders need to recognise the state's duty to provide care and acknowledge the ethical dilemmas for management of DR-TB patients, namely
the trade-off between protecting public health and respecting human rights.

HIV-positive activists march in Nhlangano on World Aids Day 2009.
HIV activism is key to influencing changes in treatment and carepolicies.

An MSF doctor attends to a patient at Matsanjeni Health Centre. Doctors are in short supply in Swaziland and attend to the sickest patients' needs

Programme services and outcomes
MSF supports decentralised, free-of-charge care and treatment for TB
and HIV in Shiselweni region. A range of services is provided through all
21 government-run health facilities in Shiselweni region, including threemain health facilities – at Nhlangano, Hlatikhulu and Matsanjeni – and18 smaller primary health clinics. These health facilities are part of theregional health network managed by the Ministry of Health, and MSF
works in close collaboration with regional MoH staff.
The long-term goal is to establish 'one-stop services' providing fully
integrated HIV and TB care at each of the 21 health facilities in
Shiselweni region. The full service package includes: HIV and TB testing
and counselling; treatment adherence counselling; TB treatment
initiation, follow-up and termination; ART initiation and refill; follow-up for
DR-TB treatment; and the prevention and management of opportunistic
infections. These services have been introduced gradually and by mid2010, 'one-stop services' were available in the three main healthfacilities and all of the 18 small primary care clinics, ten of which aresupported by MSF outreach teams on a weekly basis, while theremaining eight offer ‘one-stop services’ on a permanent basis.
MSF supports a patient-centred approach to TB treatment. Currently, TB
diagnosis, initiation and follow-up of treatment is available at the threemain health facilities and at eight primary care clinics in Shiselweni
region. Nurses initiate treatment for smear-positive TB patients andprovide follow-up care for all TB patients. Patients refill theirprescriptions on a monthly basis and are supported to complete the selfadministered, seven-days-per-week treatment regimen by expert clients.
Patients with DR-TB and/or complications are referred to a doctor at oneof the main health facilities and undergo follow-up at this health facility.
These DR-TB patients receive money to cover the cost of transport toand from the health facilities, and food packages where necessary. To
facilitate better patient access to care, all TB and DR-TB patients in theintensive phase of treatment have the option to receive injectables atthe primary care clinic nearest to their home (any one of the 18 clinics in
Shiselweni region). In addition, DR-TB patients have the option tonominate a member of their community who is trained to provide
injectables at the patient's home during the intensive phase oftreatment.
ART initiation is only available in the presence of a doctor – either at themain health facilities or at a primary care clinic on the day when the
doctor is visiting with the mobile team. ART refills are done by nurses
and dispensers at any of the 18 primary care clinics.

8

Tuberculosis services
Until the first quarter of 2008, TB management in Shiselweni region was
defined by a centralised model of care, where a clinical team based at
the national TB centre in Manzini (in the centre of the country) madesporadic and irregular supervisory visits to each regional TB centre for
initiation and termination of TB treatment. A policy of passive casedetection, combined with poor quality samples (due to an unreliabletransport system), poor quality microscopy and no proper training forstaff, contributed to late diagnosis and poor treatment outcomes.
Since MSF started its programme, the treatment outcomes of TB
patients enrolled from early 2008 onwards have improved significantly,
with the treatment success rate for new smear-positive TB cases
increasing from 54.8% in 2007 to 68.5% in the second quarter of 2009.
This improvement is largely due to six factors: i) decentralising carefrom Manzini TB centre to regional health centres (in 2008) and primarycare clinics (in early 2009); ii) improved adherence counselling anddefaulter tracing as a result of increased staffing and better training andsupervision; iii) improved case finding, contributing to early diagnosis
and earlier initiation on treatment; iv) improved drug supply andlaboratory services; v) initiation of ART for patients with TB (currently
ensured by doctors); vi) integration of ART services into TB clinics.

Intensified case finding
Given that most TB transmission is assumed to occur when patientsare still undiagnosed16, strategies to improve early case finding (andsubsequently to initiate treatment earlier and increase infection
control) have been a priority. From 2008, the MoH and MSF haveworked to increase case detection across Shiselweni region via
intensified TB case finding (ICF) among HIV-positive patients attending
primary care clinics.
All clinics and health centres have adopted a policy of ICF for HIVpositive patients upon initial diagnosis and at each follow-up. Suspect
TB patients are those who meet one or more of five criteria: coughing>2 weeks; fever >2 weeks; night sweats >2 weeks; noticeable weight
loss; and chest pains. All suspect patients then provide a sputum
sample for analysis. Sputum samples are collected in designatedareas by trained expert clients and sample quality is monitored bylaboratory specialists working in purpose-designed laboratories, withfollow-up training conducted at individual sites where lapses in quality
are identified.
Since ICF was introduced in the third quarter of 2009, the number of
HIV patients screened for TB at the primary care level has increased
more than ten-fold from 469 in Q1 2009 to 5,278 in Q2 2010. ICF
contributed to an increase in the number of TB suspects at the primarycare level from 116 TB suspects in Q1 2009 to 685 in Q2 2010. In
total, from Q1 2009 to Q2 2010, of 18,342 HIV patients screened,
2,172 were identified as TB suspects (11.8%), which reflects regional
estimates of ICF yield in ART clinics17. ICF introduction at the primarycare clinics contributed to an initial increase in TB cases registered permonth throughout Shiselweni region in 2009 (see figure 1) (which
could be due to detecting the pool of TB patients among the patientson ART), and has likely led to earlier detection of TB patients, thereby
reducing TB transmission.

Task shifting 1: Nurse-driven TB care in primary care clinics
Given the acute shortage of doctors in Swaziland, scaling up TB treatment can only happen through a model of delivery involving non-physician
clinicians as the central providers of care. Recognising the urgent need to increase access to treatment, Swaziland's Ministry of Health hasembraced the concept of nurse-initiated treatment for smear-positive TB patients. However, in 2007, TB care was still centralised and patients were
expected to travel to the TB centre in Manzini or wait for the outreach service to visit the regional health facilities. Since then, nurse-initiated TB careand follow-up has been rolled out to 21 health facilities in Shiselweni region, including 18 primary care clinics. Further decentralisation is critical to
improving access to treatment; however, several barriers remain. The human resources crisis has meant that rural clinics are often understaffed andnurses are reluctant or unable to manage the additional workload presented by TB patients. Moreover, although they are at the forefront of careprovision, nurses are not routinely trained to diagnose and initiate treatment for smear-negative TB patients, who represent the majority of TB
co-infected patients. Additional training and introduction of lay counsellors to manage counselling and other non-clinical aspects of TB care must be
prioritised to improve patient access to care.

16 Goemaere E, Ford N, Berman D, McDermid C, Cohen R. XDR-TB in South Africa: Detention Is Not the Priority. Plos Medicine 2007. 4;4:163-4.
17 Katharina Kranzer, Rein M.G.J. Houben, Judith R. Glynn, Linda-Gail Bekker, Robin Wood, Stephen D. Lawn. Yield of HIV-associated tuberculosis during intensified casefinding in resource-limited settings: a systematic review and meta-analysis. Lancet Infectious Diseases. 2010; 10: 93-102.

9Figure 1. Number of HIV patients screened for TB at the primary care level per quarter and total TB cases registered per quarter at primary careand large health facilities, 2009
HIV patients screened for TB at primary care clinics per quarter

6000

◆

5000
4000
3000

◆

◆

No of TB patients registered per quarter

◆
◆

◆

◆

2000
1000
Q1/09

Q2/09

Q3/09

Q4/09

Q1/10

Q2/10

800
700
600
500
400
300
200
100
0

Improved laboratory capacity

Photo © Jonathan Heyer

The strategy of intensified case finding has been supported by improved
laboratory capacity and an MSF-funded sample transportation system,
ensuring good quality samples and fast turnaround of results. Bleachconcentration and LED fluorescence microscopy have been introduced
at all TB laboratories in Shiselweni, contributing to improved sensitivity(15% more sensitive) and faster turnaround of sputum smear results.
MSF has also funded a three-month buffer stock of reagents forlaboratories to mitigate interruptions in laboratory services caused bystock ruptures. Since 2008, average quarterly sputum smear microscopy
has almost doubled in Shiselweni, from an average of 2,740 sputum
samples tested/quarter in 2008 to 4,477/quarter in 2010, including an
increase in new diagnostic samples screened per quarter, from anaverage of 1,768 new samples/quarter in 2008 to an average of
2,454/quarter in 2010. This increase reflects the growing diagnostic
demand due to intensified case finding. Regular internal and external
quality control provides high confidence in the quality of laboratory
diagnosis: quality control reports indicate low false negatives (<5%) and
0% false positives among all sputum microscopy. Of 22,538 diagnostic
samples tested between 2008 and the first half of 2010, 3,614 were
found to be sputum positive (16%), indicating a satisfactory quality ofsuspect finding in a high HIV prevalent context.

An MSF lab technologist prepares sputum samples before microscopy
at the Nhlangano Health Centre laboratory

18 Deribe K, Hailekiros F, Biadgilign S, Amberbir A, Beyene BK. Defaulters from antiretroviral treatment in Jimma University Specialized Hospital, Southwest Ethiopia. Trop
Med Int Health 2008.
19 Lesotho Ministry of Health and Social Welfare. Annual Joint Review Report 2009/10 FY. Health Planning and Statistics Department, May 2010.

10

Table 1. TB treatment outcomes in 2007, 2008 and first half of 2009 for new smear-positive cases
New smear-positive cases

2007 n=339

2008 n=691

1st half of 2009 n=373

Success rate

186/339 (54.8%)

500/684 (73.0%)

250/373 (67%)

Death rate

44/339 (12.9%)

100/684 (14.6%)

52/373 (13.9%)

Failure rate

24/339 (7.0%)

53/684 (7.7%)

21/373 (5.6%)

Defaulter rate

70/339 (20.6%)

26/684 (3.8%)

26/373 (6.9%)

Transferred out

15/339 (4.4%)

5/684 (0.7%)

24/373 (6.4%)

Tuberculosis outcomes
Since the programme began, treatment success among new smearpositive cases has increased from 54.8% in 2007 to 68.5% in 2009,
mainly due to a significant decrease in the defaulter rate, which fell from
20.6% to 6.3% in the same period. This is a substantial improvement,
and is due in part to increased defaulter tracing activities. The cost oftransport is frequently cited as the main reason for patients defaulting
from treatment18, and further decentralisation of treatment to primarycare clinics in the coming years is essential to ensure successful
outcomes among the growing number of TB patients initiated ontreatment.

The death rate in the first half of 2009 (13.9%) is similar to that reported
from a comparable setting in Lesotho (12%), where HIV and TB coinfection is around 80%19. In Swaziland, the high death rate appears toreflect several factors: HIV/TB co-infection; inadequate access to ART;
poor inpatient care due to a lack of human resources; initiation on
inappropriate TB treatment (due to a lack or delay of drug sensitivity
testing and culture) and late presentation by patients unable to pay thecost of the journey to TB clinics. In addition, increased defaulter tracing
activities since 2008 have probably contributed to the rise in thereported death rate.

Diagnosis was very poor when I started working here. There was no way of knowing if the drugs were
working. We just had to wait until the patient got really sick and then we suspected they were drugresistant patients. Now we send a sputum sample for each patient as early as possible. And there aresupervisors with experience in drug-resistant TB who know how to care for the patients. Things havedefinitely improved for the patient. But we get a lot of defaulters due to financial constraints, because
patients can't afford to get to the clinic. When you look at Swaziland – where the patients live andwhere the clinics are – many travel a long way to get injections. It's a burden on the patient.
TB nurse“”

Figure 2. Number of TB cases registered from 2008 to first half of 2010

1600
1400

1st half 20081200

2nd half 20081000

1st half 2009800

2nd half 2009600

1st half 2010

400
200
0
Extra-pulmonary

No sputumcollected

Smear-negative

Smear-positive

Total

11

Overall, in the first half of 2010, 25.8% of registered TB cases were
smear-positive (319/1237); the rest were smear-negative (extrapulmonary, paediatric, clinically diagnosed), or no sputum provided.
Among these, 81.4% of all patients registered were new patients(744/913) and 18.6% (169/913) were previously treated cases (thisfigure excludes cases where no sputum was available). Paediatric cases
accounted for 14.1% of the total TB cases registered during the first halfof the year.
In the next years, TB outcomes are expected to improve as a result of
key initiatives introduced in 2009-10. These include task shifting ofadherence counselling and defaulter tracing from nurses to trained lay
counsellors to increase capacity and to allow nurses to concentrate on
clinical work.

Drug-resistant tuberculosis
Drug-resistant tuberculosis (DR-TB) has traditionally been managed in
Manzini, in the centre of Swaziland. In 2009, a new DR-TB hospital
opened in Manzini. However, insufficient infection control planningmeant that only 50 beds were safe for patients, far below the number
estimated to require care. Outpatients from across Swaziland are
expected to make long and expensive journeys for follow-up care. This
heavy burden on patients, together with frequent ruptures in drug
supplies, has contributed to initial poor treatment outcomes.
To improve patient access to DR-TB care, MSF has supported
decentralisation of DR-TB care to Shiselweni region's three main

health facilities. Patients undergo three consecutive counsellingsessions provided by lay counsellors trained in DR-TB treatment
literacy, and MSF reimburses transport costs to attend treatment
initiation and follow-up, including drug refills and monitoring oftreatment uptake. Although patients must attend a TB clinic at one of
the region's main health clinics for all medical follow-up, sufficient
drugs are given to the patients to last one month, to be taken at
home. Additionally, injectable drugs are made available at any healthclinic in the region whenever needed. Multidrug-resistant TB (MDRTB) patients also have the option to nominate a member from theircommunity – a community treatment supporter – who is trained toprovide injectables at the patient's home during the intensive phase oftreatment. This decentralisation of injectables to primary care clinics
and communities is an important step towards ensuring access totreatment and reducing defaulter rates. In TB clinic waiting areas, laycounsellors run health education sessions and facilitate monthly
support groups for DR-TB patients. Defaulter tracing of MDR-TB
patients is done by an outreach nurse.
Swaziland has seen an important turnaround in MDR-TB
management since June 2009, when the MoH published new nationalguidelines for MDR-TB treatment and care. These new guidelines, towhich MSF contributed with technical input, support a stronger drug
regimen, improved drug management procedures and training forstaff, as well as guidance for decentralised care, which includes aprovision for community support treatment for DR-TB patients where
no alternative care is possible. A DR-TB expert committee has also
been established to provide clinical support for DR-TB casemanagement.

MDR-TB prevalence – a national drug sensitivity survey
Result of drug-resistance survey (January 2009-February 2010)
Multidrug-resistant 19.30%

Polydrug-resistant
5.50%

Between January 2009 and February 2010, a cross-sectional
survey was conducted to measure MDR-TB prevalence among all
newly diagnosed smear-positive TB patients. Samples from 633
patients (352 new cases, 281 previously treated cases) werecollected and shipped to the Supranational Laboratory for
Mycobacteria in Borstel, Germany, for culture and drug
susceptibility testing (DST).

Twenty-seven (7.7%; 95%CI: 4.8%-10.5%) MDR isolates wereidentified among new cases. Ninety-five (33.9%; 95%CI: 28.3% Monodrug-resistant
39.3%) MDR isolates were identified among previously treated
5.70%
cases. The prevalence of resistance was highest among patients'previously treated with failure' (>85% MDR-TB). More than 60% of
No resistancethe resistant TB strains presented additional resistance to69.50%
pyrazinamide. Ethionamide was the second line drug to which thestrains presented resistance more frequently (>45%). One
extensively drug-resistant (XDR-TB) strain was identified among the previously treated cases.
This MDR-TB prevalence is higher than expected, and higher than the prevalence in neighbouring countries with more or less recent data. Indeed,
the estimated MDR-TB prevalence in South Africa is 1.8% (95%CI: 1.5-2.3) in NC and 6.7% (95% 5.5-8.1) in PTC (data from the 2002 national
drug resistance survey (11)); and in Mozambique it is 3.5% (95%CI 2.5-4.7) for NC and 11.2% (95%CI 4.2-30.0) for PTC (data from the 2006
national drug resistance survey and multidrug and extensively drug-resistant TB. 2010 global report on surveillance and response. Geneva: World
Health Organization; 2010.). In light of the survey results, systematic drug susceptibility testing for all diagnosed TB cases is recommended before
starting TB treatment, including the use of LPA (Line Probe Assay) for smear-positive patients.

12

Detection of patients withdrug-resistant TB

To facilitate DST for TB patients enrolled, MSF has supported capacity
development at the National Reference Laboratory in Mbabane.
Recruitment of a laboratory technologist trained in culture and DST
techniques has helped more than double the number of samples
processed, from 1,875 in 2008 to 4,226 in 2009. MSF also funds a
courier service to safely deliver sputum samples to the Supranational
Reference Laboratory in Pretoria (MRC) for Line Probe Assay and/or
culture and DST.
Overall, detection of DR-TB cases has increased in Shiselweni region
from 42 cases enrolled on Category 4 treatment in 2007 and 2008, to 80
cases in 2009, and 27 cases in the first half of 2010. Data from the

Photo © Jonathan Heyer

In late 2007, when MSF started working in Shiselweni region, laboratory
capacity for drug susceptibility testing (DST) was very limited and quality
was poor due to understaffing, stock ruptures and inadequate space andequipment. As a result, culture and DST were only requested for people
who had failed Category 1 or 2 treatments. It became apparent that thescale of DR-TB warranted a more aggressive case finding approach,and in June 2009 a new DR-TB case finding algorithm was introduced
recommending culture and DST for all TB patients enrolled, before
starting TB treatment.

A lab technician takes a blood sample from a patient. Phlebotomy isperformed by lab technicians in the main centres, but additional cadres
have been trained to take blood samples at clinics

Earlier diagnosis of MDR-TB patients
Rapid diagnosis and early initiation of effective treatment are essential to reduce the risk of transmission and improve treatment outcomes for thegrowing number of MDR-TB patients. To support early case detection of drug-resistant cases and prevent amplification of new drug resistance, MSF
has decided to introduce routine Line Probe Assay and/or culture and DST screening for all TB patients in 2010, making use of the NRL in Mbabane
and the Supranational Reference Laboratory in Pretoria. MSF also plans to support implementation of Line Probe Assay capacity at the National
Reference Laboratory (by providing human resources, training and mentoring) and Thin Layer Agar (TLA) methodology for culture diagnostic andisoniazid and rifampicin susceptibility testing in Shiselweni region. By introducing the TLA technique at the new TB laboratory in Nhlangano, MSF
aims to demonstrate the benefits of this technique as a fast, simple, affordable and effective diagnostic measure appropriate for use in rural settings.

Task shifting 2: Providing injections for DR-TB treatment in the community
Even though the provision of injectables for MDR-TB treatment is decentralised to rural clinics, and transport costs from home to the clinic arereimbursed, patients on injectables are still expected to travel long distances to receive daily treatment. Often, this leads to problems related tocompeting priorities such as work or family support. Community treatment supporters are an innovative solution to making DR-TB treatment
accessible to all who need it. The community treatment supporter is a community member selected by the patient – often an existing rural healthmotivator – who has a recognised role in the community. Community treatment supporters are provided with training and supervision from a nurse
to provide daily injections and supervise treatment uptake at or near a patient's home for the duration of the intensive phase of treatment. MSF
experience in 2009 demonstrated 100% adherence for injectables among MDR-TB patients who were supported by a community treatment
supporter (15/15+5 in 2010) patients, including 8/15 who had completed treatment). Currently, the national health strategy concedes that
community treatment supporters are a viable approach, but only in exceptional circumstances. Results from the recent DST survey provide
compelling evidence for the need to urgently scale up effective MDR-TB treatment. Given the critical shortage of health workers and lack of
inpatient capacity, and the large proportion of Swazis living in rural areas far from primary care clinics, the community treatment supporter approachis the only option to ensure treatment success for MDR-TB patients living in remote areas of Swaziland.

13

National TB Control Programme shows a progressive increase in thenumber of MDR-TB cases detected each year throughout Swaziland,
from 35 cases registered in 2007 to 317 registered in 2009.
Anecdotal evidence from clinics in Shiselweni region where MDR-TB
contacts were not screened for TB, even when associated with
important risk factors (HIV-infected or children <5), suggests a need forintensified contact tracing, as well as addressing other missed
opportunities for diagnosis.

Multidrug-resistant tuberculosis treatment
outcomes
At the end of June 2010, 123 patients were on MDR-TB treatment inShiselweni region. The increase in culture conversion at six months –from 9/32 (28%) in 2008 to 40/64 (62.5%) patients enrolled in the first
three-quarters of 2009 – is an indication of improved treatment
management, resulting from earlier diagnosis and initiation on
appropriate treatment, as well as from improved follow-up. Although it isearly to draw definite conclusions, these intermediate data areencouraging.
However, there are still barriers to sustainable DR-TB care. Due to theerratic supply and management of second line anti-TB drugs at a centrallevel, MSF is currently ensuring that sufficient DR-TB drugs are provided
to treatment facilities in Shiselweni. A complete and accurate supply
must be taken on by the National TB Control Programme to ensuresustainability in the long run. In addition, even with injectables available
at primary care clinics, treatment is still out of reach for many patients in“”rural areas. Nationwide, the increasing number of MDR-TB patientsdemands a fully decentralised model of care, including the strengtheningof DR-TB drug supply from a central to a peripheral level, and active
participation by community treatment supporters in the intensive phaseof treatment.

A 'one-stop service' for TB and HIV care
In Shiselweni, more than 80% of TB patients are HIV-positive, and TB is
the leading cause of morbidity and mortality among HIV-positive people.
Previously, there was no integrated HIV/TB service for co-infectedpatients, and TB patients were referred to ART clinics for separate caremanagement. This contributed to an increased risk of nosocomialtransmission, an unnecessary duplication of work by healthcare workers
and confusion, and long waiting times for patients.
Integrating TB and HIV care for co-infected patients was identified as anurgent measure to improve treatment outcomes. MSF has developed'one-stop services' for integrated HIV/TB care at 21 health facilities,
including 18 primary care clinics and the three main health facilities in
Shiselweni region. These 'one-stop services' provide a comprehensive
package of care for TB patients and HIV co-infected patients, including
routine HIV testing and counselling (HTC) for TB patients, education on
HIV and TB transmission and treatment, adherence counselling and all
TB treatment and ART with follow-up care. Care for HIV patients who do
not have active TB is provided at separate ART clinics.
According to data from 2009, most (2,464/2,697=91%) of the patients on
TB treatment accept the offer of HIV testing. As mentioned earlier, morethan 80% of TB patients are co-infected with HIV. However, less than

From where I live, the nearest road is 2 kilometres on foot. I went every day to the clinic for twomonths to get my daily streptomycin injection. I left the homestead at 4 am, arrived at 9 or 10 am at
the clinic, then reached home again at around 4 pm. A few times I rented a donkey for transport. Now
I have MDR-TB, it means I have to do this journey every day for six months! I'm a sick patient. How
can I travel every day like this?
MDR-TB patient
The difference between patients I see at the clinics and those getting injections at home is really big.
Before, some patients were failing to come to the clinic for their injections, and they had poor
treatment outcomes. They were travelling long distances to get to the health clinic for the injections,and they were sick too. Now they are getting injections at home from the community treatment
supporters. You can really notice them improving. It's what the patients want too.
Outreach nurse
At the end of May we had to initiate a school-going child on DR-TB treatment. He wanted to go toschool – it was really important to him. But to get to the nearest clinic would take most of the day,and there would be no chance of him going to school for six to nine months. His aunt knew someone
who could be a community treatment supporter, and this person was trained on the job at thehomestead. She learned very quickly to do the injection – her husband was a diabetic and she had
injected him before. The boy is so happy that he can take his exams and not lose a year of school.
DR-TB nurse

Photo © Jonathan Heyer

14

A community facilitator carries out an awareness session on TB and HIV, one of many that take place in rural communities

half (907/1,961 = 46.3%) of the patients with this dual infection receive
both treatments (compared to 33% in 2008). The main reasons for thisrelatively low percentage are: a) a misperception among patients that
ART and TB treatment should not be taken simultaneously, resulting intheir refusing treatment; b) periods when it has been hard to access theCD4 test; and c) a complete dependence on doctors for the initiation ofART, who visit the clinics just once or twice per week.
Efforts need to be stepped up to improve service provision and get more
co-infected patients on ART. The recently approved MoH strategy
proposing ART initiation for all HIV-infected TB patients, irrespective of
CD4 count, should go a long way towards ensuring this.

Psychosocial support among patients andin the community
Recognising the importance of awareness of HIV and TB among
patients and the wider community, the programme has a psychosocial
support component which aims to reduce stigma, encourage testing,
improve early case finding and improve treatment adherence. Schools,
traditional meeting places and workplaces provide opportunities fortrained expert clients to run health awareness sessions and distributeinformation and condoms to the community. In health clinics, expert
clients provide three pre-ART initiation counselling sessions for patients,
as well as individual and group therapeutic education sessions to informpatients about their HIV and/or TB treatment and to promote positive
living with HIV. Expert clients also run drama groups and other peer
support groups to support adherence to DR-TB treatment.

In mid-2010, additional resources were allocated towards improving
health awareness. A greater number of well trained, better-supervised
staff has contributed to a two-fold increase in the number of pre-ART
counselling sessions since the beginning of the year, and a three-foldrise in the number of health education sessions held. These additional
resources, and the links forged between patients, communities andexpert clients, are likely to contribute to better outcomes in terms oftreatment adherence and defaulter tracing. An early indicator is a 40%
reduction in the number of missed clinic appointments in June 2010 (54patients) compared with the previous month (96 patients).

Infection control
Most TB transmission occurs among undiagnosed patients. For thisreason, the best way of tackling infection control in the community is byimproving case finding at the primary care level and supporting patientsin completing their treatment. This is particularly important in a high HIV
prevalence setting such as Swaziland, where TB continues to be theleading cause of mortality among people living with HIV and AIDS.
Administrative, environmental and personal protective measures havebeen introduced at all healthcare facilities to reduce the risk of
nosocomial TB transmission20. For example, appropriate measures
have been put in place to ensure safe sputum collection and diagnosis,
including outside areas specifically designated for sputum collection.
Cough triage is implemented in all outpatient facilties to identify promptly
people with chronic coughs and to fast-track patients with TB symptoms
so that they do not put other patients in waiting areas at risk.

15

Appropriate safety equipment is provided for laboratory technicians, andstaff working in close contact with TB suspects use N-95 respirators.
Infection control awareness is also an integral part of all training for
healthcare workers. A sputum sample transportation system has
contributed to faster turnaround times for smear testing and earlier
initiation on treatment. To improve the management of infection control
in the community, contact and defaulter tracing is increasingly handled
by expert clients with the time and resources to provide acomprehensive tracing service. Expert clients also run awarenessprogrammes for TB patients on household infection control measures
such as cough hygiene, patients sleeping alone and receiving visitors
outside, and keeping windows open. MDR-TB patients receive a home
visit within two weeks of treatment initiation to improve infection control.

HIV testing and counselling
Testing and counselling is the entry point to effective HIV care, treatment
and support. Rapid HIV testing is accessed via the regional healthsystem's 18 primary care clinics; however, in clinics where there is often
only one nurse on duty for a catchment population of between 7,000
and 16,000, and there are many urgent health needs, testing has notalways been a priority.
MSF has boosted capacity for HIV testing and counselling in two ways:
through the recruitment of skilled HIV tester/counsellors (HTCs) who
work at the primary health clinics (either on a daily basis or as part of amobile outreach team); and by increasing awareness of services“”

through expert clients working in health clinics and in the community topromote HIV testing and counselling and to reduce stigma. In 2009, thenumber of people testing for HIV each month at the primary clinic level
nearly doubled, from 474 in January to 799 in December, reflecting therecruitment of an additional five new HTCs in February. Overall, 10,689
people were tested for HIV in 2009, representing approximately 6%(10,689/170,689) of the estimated catchment population for primary careclinics in Shiselweni. Of these, 2,415/10,689 (22.5%) were found to be
HIV positive, and 1,045/2,415 patients who tested positive were initiatedon ART treatment or referred for initiation.
In May 2010, MSF introduced permanent community-basedtester/counsellors at each primary clinic in Shiselweni to increase theoverall number of people tested for HIV, with a corresponding increase
in HIV testing at clinics, from 911 patients tested in May 2010 to 1,617
tested in June 2010. The total number of people tested is expected torise as the new permanent tester/counsellors undergo additional training
and become well established in their roles. To further increase
community awareness of testing and counselling services, MSF expects
to increase its collaboration with the existing network of 1,050 rural
health motivators, who have the capacity to reach more than 26,000
homesteads in Shiselweni region.
The diagnosis of HIV among children was greatly facilitated by the
introduction of the Dried Blood Spot (DBS) test in August 2009. Since
then, 227 children have undergone testing. However, the majority ofchildren who are HIV-positive are still not on treatment as a result of
poorly managed follow-up of at-risk children.

I was not actually surprised when they told me I was HIV positive, because I knew I had had a lotof girlfriends and never used condoms. To me, being HIV positive has prompted me to change my
behaviour in a big way, although it's unfortunate that it took that to make me change. Now I am anexpert client and I encourage people to go for testing.
Sometimes there are people who do not believe me when I tell them my status because they see ahealthy looking person. While it's surprising that people still think HIV status can be seen insomeone's face, I must say I am encouraged when even elderly people stand up in these meetings
to say that it's foolish to be afraid to know one's status in this day and age. Those who refuse to
stand up and get tested are the ones who are getting buried daily.
HIV patient

20 WHO 1999. Guidelines for the prevention of tuberculosis in health care facilities in resource-limited settings Available at:
http://www.who.int/tb/publications/who_tb_99_269/en/index.html

Photo © Jonathan Heyer

16

Preparing drugs for patients is a task that dispensary assistants can perform under the supervision of nurses
Figure 3. HIV testing in Shiselweni region, January 2009-June 2010
HIV testing in Shiselweni region, January 2009-June 2010
Recruitment of permanentcommunity tester/counsellors

Recruitment of HIV
tester/counsellor
1800
1600
1400

Total no of patients tested for HIV per month

1200
1000

Total no of patients testing positive

800
600
400
200

2010

May

June

April

March

February

January

December

OctoberNovember

September

July

2009

August

May

June

April

March

February

January0

17Figure 4. Cumulative number of persons ever initiated on ART and currently on ART in Shiselweni region, 2008-2010
ART data 2008-2010
12000
10000

Cumulative no of persons ever put on ART at the8000

end of the reporting period

6000
4000

Total no of persons currently on ART at the end of2000

the reporting period

0
Q1

Q3

Q2

Q4

2008

Q1

Q2

Q3

2009

Antiretroviral therapy
In Shiselweni region, an estimated 40,000 people are living with HIV,
including an estimated 19,808 in clinical need of ART as of mid-201021.
One of the major objectives of the programme has been to make careand treatment for people living with HIV accessible at the primary carelevel. In 2008, MSF introduced access to ART refill at nine primary careclinics and, in mid-2009, ART initiation at the primary care level was
implemented throughout the region, including local access to CD4 counttesting via a blood sample transport service.
Decentralising access to ART has contributed to an increase in the total
number of patients initiated on treatment in Shiselweni region. Since
2008, the cumulative number of patients ever initiated on ART and thenumber of patients currently on ART has increased: from 3,996 currently
on ART in 2008 to 8,813 in the first quarter of 2010; and 4,865 ever
initiated on ART in the second quarter of 2008 to 9,906 in the firstquarter of 2010. The steady increase in the proportion of patients still on
ART reflects efforts to provide regular therapeutic and adherence
counselling for patients and defaulter tracing services provided by MSF
outreach nurses.
In the first quarter of 2010, 9,906 (50% of estimated eligible patients)
were on ART, which is below the recommendation that 85% of adults
and 90% of children eligible for ART are on treatment. Currently,
national recommendations stipulate that ART can only be initiated by adoctor, yet, with the national staffing crisis, the number of doctors in the
country is nowhere near what is needed to initiate everyone in clinicalneed of ART. Although improvements in the procurement, supply andmanagement of antiretroviral drugs were noted in the second half of2009, supply to the clinics and overly bureaucratic drug ordering

Q4

Q1
2010

processes remain an indication of the hurdles in improving decentralised
ART initiation. Finally, demanding that patients attend three counsellingsessions prior to starting ART is unrealistic, given the journey time andcosts associated with travel to the clinic.

Isoniazid Preventive Treatment
MSF advocates isoniazid preventive therapy (IPT) for HIV-positive
patients who do not have active TB. A pilot programme implementing
IPT for all patients on ART who are co-infected with TB was launched in
Nhlangano's health centre and three primary care clinics in 2009. All
patients on ART are screened for TB and put on a minimum six monthsof treatment with isoniazid; no tuberculin skin test is performed.
All patients enrolled on IPT are patients who are on ART without active
TB. IPT is not yet offered to pre-ART patients. IPT is initiated by an MSF
nurse in the clinic and only if the nurse encounters a problem is thepatient referred for assessment by a doctor. Out of 292 patients enrolled
on IPT, 91% completed treatment successfully. None of them died whileon treatment. Only 1% developed active TB while on treatment, while
8% defaulted due to poor adherence or side effects.

Co-trimoxazole
Efforts to provide co-trimoxazole prophylactic treatment (CPT) topatients who require it are hampered by delayed drug supply from theCentral Medical Stores. MSF supports CPT for people with HIV who areon ART and contributes to supplying facilities to fill this supply gap.
However, given the proven benefits of CPT, the uninterrupted supply of
CPT should be addressed as a matter of urgency22.

In line with the most recent WHO recommendations, the CD4 count threshold for the initiation of ART has increased from 200 to 350. This change
was adopted in Swaziland from mid-2009. It has had a significant impact on the number of HIV-positive people who are eligible for ART, which isprobably twice what it was previously. The new situation raises many questions: foremost among them is whether the Swazi Ministry of Health has
the financial, human and management capacity to respond to the needs of thousands more people eligible for treatment, unless increased
decentralisation and the rapid implementation of task shifting strategies take place.
21 Based on new WHO criteria CD4 <350cells/μ
22 Date A, Victtoria M, Granich R, Banda M, Fox MY, Gilks C. Implementation of co-trimoxazole prophylaxis and isoniazid preventive therapy for people living with HIV
Bulletin World Health Organization 2010; 88:253-259

18

Figure 5. HIV patients eligible for ART vs those enrolled on ART, 2008-2010
HIV-positive patients eligible for ART vs patients enrolled on ART in Shiselweni region
45000
40000

Estimated number of HIV-positive people

35000

HIV-positive patients eligible for ART

30000
HIV-positive patients enrolled on ART

25000
20000
15000
10000
5000
0

Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q42008 2008 2008 2009 2009 2009 2009 2010 2010 2010 2010

Task shifting 3: The role of the expert client HIV tester/counsellor

Photo © Jonathan Heyer

Given the acute shortage of professional health workers in Swaziland, delegating responsibility for HIV testing and counselling (including rapid
testing, pre and post-ART counselling, including phlebotomy, CD4 count, haematology and biochemistry tests) from nurses and nursing assistants toexpert client HIV tester/counsellors (HTCs) is one way to meet the increasing demand for ART. MSF is introducing an innovative and cost-effective
approach to expanding HTC coverage by recruiting and training expert clients from the community. Utilising local capacity that involves patients incare management has several benefits: staff do not have to travel long distances to the clinic and are therefore more likely to reach work on time; staff
do not require accommodation, thereby avoiding the problem of inadequate or non-existent housing for MoH staff; keeping responsibility for HTCs
within the local community isempowering and can promote
Expert clients play a
open discussion about HIV andkey role in assisting
ART and help to reduce
patients at clinics
stigma; and local staff haveand in theextensive local knowledge.
community
Involving service users (expert
clients) in service provision is
also a way to tap into a
growing resource of people
with existing knowledge of TB
and HIV. The HTCs represent a
community-based health cadrethat fulfils an essential role in
ART scale-up and reflects thelimitations of the national
health budget. By
demonstrating that HTCs canprovide high quality services
throughout Shiselweni region,
MSF will advocate forabsorption of the HTC function
into the existing national
healthcare system.

Photo © Jonathan Heyer

With some tasks being shifted to new cadres, nurses have more quality time to spend with patients

Strengthening the healthcare
system to provide TB and HIV care
Task shifting
To address the human resource shortage and improve national
healthcare capacity, MSF has adopted a strategy of task shifting, inwhich responsibilities for care are delegated to lower cadre healthworkers, who receive mentoring and supervision to ensure thecontinuous provision of high quality care (see boxes on task shiftingfrom nurses to HIV tester/counsellors; from nurses to community
treatment supporters; and from pharmacists to lay dispensary
assistants).

Improving health systeminfrastructure
A significant investment in infrastructure has been vital to optimise
capacity for a growing number of TB cases. MSF has subsidised therenovation of three new laboratories for TB diagnosis in Shiselweni's
main health facilities. In 2010, MSF started construction of a new DR-TB
ward that will allow for short-term hospital stays for DR-TB suspects insingle rooms with natural ventilation, reducing the risk of nosocomialtransmission and increasing access to inpatient care (where necessary)at the regional level. MSF is also building a TB laboratory next to the
new ward and situated behind Nhlangano's health centre.

Staff health
A major cause of attrition among health workers in Swaziland is illness
and death, including an estimated 3-4% loss of all staff to HIV/AIDS and
TB each year. Healthcare workers are reluctant to seek care in thesame facilities as their patients, and this stigma contributes to highmorbidity and mortality rates. Improved healthcare for staff is an
important means of improving the availability of health services. MSF
advocates for regular health check-ups for all staff in Shiselweni region,and supports staff to attend the national 'Wellness Clinic', a mobile
service established in 2006 that provides comprehensive healthcare to
health workers in a confidential environment23.

20

Mobile teams

Improving laboratory services

In outlying clinics where staff shortages are particularly acute, MSF
outreach teams have boosted MoH capacity. Each outreach teamincludes a doctor, a nurse, an HIV tester/counsellor, a data clerk and apharmacy technician. The team provides support to MoH staff in testing
and counselling for HIV; collecting blood samples for CD4 andbiochemistry; sputum collection for microscopy; diagnosis of TB andopportunistic infections; initiating patients on ART and TB treatment;
follow-up of patients on ART and TB treatment; and referral of patientsto health centres and hospital when necessary. The team also assists inthe dispensing of drugs as well as regularly collecting data.

Quality and continuity have been persistent problems in laboratories in
Shiselweni region. Poor equipment maintenance has led to a frequentinterruption of services at the laboratories, and the solution until now
has been to transfer samples to the nearest working laboratory, doubling
the workload for staff there as a result.

The mobile service is logistically challenging: since the programmebegan, five teams have provided health services at least once a week toa maximum of 15 clinics spread out across an area spanning 3,790 km2.
In Swaziland, the outreach teams have enabled MSF to start providing
healthcare support to outlying primary care clinics earlier than if the
programme had relied exclusively on setting up permanent
decentralised services. In the long term, mobile teams will be phasedout and services will be provided on a permanent basis by boosting
existing capacity at clinics through the recruitment of additional
permanent trained staff members who will gradually be absorbed into
the MoH. In 2010, the Shiselweni Regional Health Authority is expected
to approve the integration of mobile team staff into three primary careclinics on a permanent basis. Given the challenges associated withrunning outreach teams, the direct integration of health services into
existing health facilities is desirable and encouraged where resources
allow.

Drug supply
TB drug management in Swaziland is currently overly bureaucratic andunreliable. There are three separate drug supply chains – for ARVs, for
TB drugs, and for all other drugs – each with its own request form andtransport system. Stock ruptures and incomplete supplies to facilities
have been frequent. MSF is supporting the MoH in the short term
through the provision of emergency back-up stocks – in 2009, forexample, an emergency back-up stock of first and second line TB drugs
was able to cover a gap left by a national drug stock-out. In parallel withthese initiatives, MSF is supporting MoH nurses to place drug orders
and is organising the delivery of drug requests and drug stocks between
the National TB Control Programme and clinics in Shiselweni. In 2010,
MSF has continued to cover the huge shortages in the supply of secondline TB drugs throughout Shiselweni region and has received approval
from the Green Light Committee to have access to second line drugs for
300 patients in Shiselweni region.

To improve overall laboratory capacity, MSF has supported the
procurement of additional equipment (including for point-of-carebiochemistry testing analyser for alanine aminotransferase, creatinine
and potassium in case of laboratory malfunction) and has advocated for
doubling up all equipment in all regional laboratories, both to ensure
continuity of laboratory services and to increase capacity to deal withthe growing number of HIV and TB patients as case finding increases.
To bring essential tests closer to the patients, and to facilitate improved
care and follow-up of patients, MSF has supplied the necessary tools foron-the-spot urine analysis as well as pregnancy, haemoglobin andsyphilis tests at primary care clinics. HTCs are trained to conduct tests
and interpret results accurately. Implementing this package in all primarycare clinics would dramatically scale up patient management at the local
level. In 2010, MSF introduced these diagnostic facilities at five
additional clinics. Recent quality control of these tests performed atprimary care clinics showed 100% concordance with the control results.
Laboratories are subject to quarterly internal and external control (via
the South African National Health Laboratory Services)24, involving arandom rechecking of sputum samples. Consistently good results havebeen reported from all facilities. The maintenance and supervision of theuse of diagnostic equipment at primary care clinics is done on a monthly
basis.

Decentralising sample collection
MSF has established a well functioning sample transportation system for
rapid turnaround of sputum testing for samples collected at 18 outlying
clinics. As a result, patients no longer have to make expensive andlengthy journeys to laboratories to provide sputum samples, and fast,quality diagnosis allows treatment initiation for all smear-positive TB
cases. This has contributed to improved treatment outcomes in 2009.
The sustainability of this system, including training nurses to package
and document samples in the future, may be guaranteed by acountrywide system for sample transportation currently being negotiatedbetween the MoH and non-governmental partner organisations.

23 Baleta, A. Swaziland nurses the wellbeing of its health workers. World Report. The Lancet Vol 371 pp.1901-1902, June 7, 2008.
24 http://www.nhls.ac.za/

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Task shifting 4: Training laboratory and lay dispensary assistants

Photo © Frédéric Matte

Swaziland's human resource crisis has also hit laboratory and pharmacy services. There are no formal training courses for microscopy, pharmacy orlaboratory technicians in Swaziland, and MSF has had to recruit from neighbouring countries to boost MoH capacity. In the long term, increasing thenational skills base is critical in order to guarantee the future of laboratory services in Swaziland. The Ministry of Health acknowledges theimportance of building capacity in laboratory skills, and in 2009 organised two week-long courses to train lay people in microscopy skills. A similar
approach to increasing pharmacy capacity would lessen the burden for nurses, who are currently responsible for drug dispensing in most healthfacilities. MSF is currently developing a dispensary assistant training course, based on a successful model in Malawi, whereby educated lay people
are selected for on-the-job training and mentoring by pharmacy technicians, following a fast-track curriculum modelled on existing courses in South
Africa and expected to be accredited by the Swazi Ministry of Health.

At the TB clinic at Matsanjeni Health Centre, co-infected patients can also receive treatment for HIV

25 Shulman D, Jobarteh K, Makani E, Mtewa S, Mapwelemwe A, Manjomo A, Crocker J, Joseph K. Task-shifting in the pharmacy: a framework for expanding andstrengthening services in rural Malawi. 5th IAS Conference on HIV Pathogenesis, Treatment and Prevention, Cape Town, 2009. Abstract CDD094.

Photo © Jonathan Heyer

22

Expert clients contribute a great deal to improving patients' treatment literacy and knowledge of HIV- related issues

Current challenges and futurepriorities
Improving human resources management
Given the severe shortage of health workers in Swaziland and thegrowing demand on healthcare resources, task shifting is vital tomanage the HIV/TB co-epidemic. Delegating responsibilities to lower
cadres of workers (from doctors to nurses, and from nurses to expert
clients and dispensary assistants) is proven to be an effective model ofcare delivery in contexts comparable to Swaziland. Lower health cadres
are also more likely to stay within their communities and offer apermanent service than more mobile, higher paid staff. Training,
mentoring and supervision for all new recruits must be routinely
provided through the MoH to improve the quality of care within theexisting health network capacity. Reversing the brain drain on healthcare
professionals through improved working conditions and better
healthcare for staff to reduce attrition rates due to HIV/AIDS must also
be prioritised.

In Shiselweni region, nurses and nursing assistants manage an averageof 29 consultations per day per nurse. This suggests that in many
clinics, nursing staff would have the capacity to manage additional
clinical management workloads if health education, dispensing andcounselling tasks were shifted to lower cadres of health worker.

Integrated HIV/TB care at primary carelevel
Providing integrated TB and HIV services at all primary care clinics inthe region is an important step in providing universal coverage for TB
patients and people living with HIV. Decentralisation will rely on
recruiting well-trained and regularly supervised health workers, with

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Task shifting 5: Nurse initiation on ART
More than a quarter of Swazis aged 15-49 are living with HIV. In Shiselweni region, an estimated 40,000 people are infected, including an
estimated 19,808 in clinical need of ART in the first quarter of 2010. In early 2010, 9,906/19,808 (50%) were receiving the quality of care theyneeded. Urgent measures are required to increase capacity to manage the growing number of people in need of HIV-related care. By adopting amodel of care delivery that relies on nurse initiation of treatment, Swaziland could start to rapidly scale up access to ART. Nurse-initiated ART isproven to be a safe and effective model of care delivery for adults and children in high HIV prevalence contexts26,27; this has recently been
confirmed in a randomised trial28. In Rwanda, a study found that task shifting ART initiation and monitoring would increase doctor capacity for nonrelated HIV work by 183%.29 In Lusikisiki, in rural South Africa, task shifting facilitated district-wide access to ART within two years30. In Lesotho, amountainous country with a large rural population and an HIV/TB co-infection rate comparable with that of Swaziland, a nurse-driven, communitysupported HIV/AIDS programme at the primary care level enabled enrolment of 11,000 people in HIV care and treatment initiation of 4,000 patients
within a three-year period, with 86% of adults and 93% of children remaining in care after 12 months on ART31. In Swaziland, the current model ofcare delivery relies on a doctor for ART initiation. This approach fails to meet the demand for treatment, which is already huge and is still
increasing; it does not allow adequate time to provide quality care; and it is completely unsustainable. In Shiselweni, the differential capacity ofnurses and doctors (there are 17 MoH doctors in the region, none of whom visit primary care clinics) reinforces the need for Swaziland to review its
policy of ART initiation by doctors. Nurse-initiated ART must be introduced urgently to scale up access to treatment and to improve the overall
quality of care for people living with HIV.

adequate drug supplies and appropriate infection control at healthfacilities. Efforts must focus on the simultaneous decentralisation of TB
and HIV services to cater to the needs of co-infected patients, toincrease treatment adherence and to reduce the risk of transmission or
emergence of new drug resistance. By establishing permanent sites for
ART and TB initiation and treatment, MSF will pave the way for longterm care at the local level.

Reinforcing drug supply andmanagement
Currently, drug supply management is defined by parallel, unreliable andwork-intensive ordering and transportation systems. Simplifying andstreamlining these systems is necessary in order to meet growing
treatment demand with the limited resources available. With routine
supervision and mentoring, the new cadre of trained dispensary
assistants will improve the capacity and accuracy of drug management
at the clinic level; however, the inevitable increase in long term ART
demand calls for more innovative solutions to drug dispensing. A modelof chronic care for stable patients piloted in Khayelitsha, South Africa,
where two-monthly and six-monthly ART refill is provided via 'adherence
clubs', is a feasible option to maintain ART enrolment in a resourcelimited setting at the same time as reducing waiting time for patients32.

drug orders. A national essential drug list for Swaziland is currently
under development and will contribute to this goal. The introduction ofregional pharmacists and warehouses to manage drug orders at theregional level is currently under discussion, and is another step towards
a more effective system of drug management. Finally, Swaziland's MoH
must also commit to increasing the national budget to cover the growing
cost of drugs related to an increase in the overall number of patients
initiated on ART and TB treatment, and on DR-TB treatment inparticular.

Data management
The current data management system at primary care clinics iscomplicated by the use of multiple registers and different systems(computerised and paper-based) for HIV, TB and DR-TB patients thathinder performance evaluation and duplicate the workload. Among the
major challenges are the frequent breakdowns of computers andsoftware used by the data clerks, combined with poor maintenanceservices. Another challenge is the access to raw data to analyse acohort of patients enrolled in the ART programme. There is also anurgent need to analyse data collected since the start of the drugresistance component of the TB programme, which requires anelectronic database to be in place. There have been recent efforts toestablish a combined database for both ART and TB services.

At the national level, the introduction of treatment guidelines for hospitaland primary care is strongly recommended to standardise drug use and26 World Health Organization: Treat, train, retain. Task-shifting: Global recommendations and guidelines. Geneva, 2007. Available:
http://www.who.int/healthsystems/task_shifting/en/.
27 Callaghan M, Ford N, Schneider H. A systematic review of task shifting for HIV treatment and care in Africa. Human Resources for Health 2010. 8:8.
28 Sanne I, Orrell C, Fox MP, Conradie F, Ive P, Zeinecker J, Cornell M, Heiberg C, Ingram C, Panchia R, Rassool M, Gonin R, Stevens W, Truter H, Dehlinger M, van der
Horst C, McIntyre J, Wood R; for the CIPRA-SA Study Team. Nurse versus doctor management of HIV-infected patients receiving antiretroviral therapy (CIPRA-SA): a
randomised non-inferiority trial. Lancet. 2010 Jun 15. [Epub ahead of print]
29 Chung J, O'Brien M, Price J, Shumbusho F. Quantification of Physician-time Saved in a Task Shifting Pilot Program in Rwanda. AIDS 2008 - XVII International AIDS
Conference. Abstract no. WEAB0205
30 Bedelu M, Ford N, Hilderbrand K, Reuter H. Implementing Antiretroviral Therapy in Rural Communities: the Lusikisiki model of decentralized HIV/AIDS Care. Journal of
Infectious Disease 2007; I96(Supplement 3):S464-8.
31 Nurse driven, community-supported HIV/AIDS treatment at the primary health care level in rural Lesotho, 2006-2008 programme report, Médecins Sans Frontières
32 Providing HIV/TB care at the primary health care level, Khayelitsha Annual Activity report 2008-2009. MSF, Western Cape Province Department of Health, City of Cape
Town Department of Health, University of Cape Town, Centre for Infectious Disease Epidemiology and Research24Long term adherence to ART and
TB treatment
As more people are initiated on ART, more needs to be done to ensure
widespread adherence in the long term. Increasing treatment literacy
among patients must therefore be prioritised in the coming months andyears.

Drug-resistant TB

By the end of 2010, the Ministry of Health is expected to have takenover three nursing positions that were introduced by MSF to increase
the capacity to provide TB and HIV care at three integrated primary careclinics. This is the first step in a multi-phase handover process that will
involve ongoing advocacy for more government-funded positions
throughout the health system in Shiselweni region to take over services
provided at fully integrated primary care clinics. Given the financial
limitations of the national health budget, MSF has taken measures tointroduce new health cadres who are trained and supervised to provide
effective, high quality care and unburden the existing network ofhealthcare staff. Currently, a number of services are provided by MSF
doctors who – given the human resource crisis in the country – will bedifficult to replace. Task shifting of ART initiation from doctors to nurses
is an essential step in improving ART access with the limited resources
available and in ensuring that the programme is sustainable. MSF
mobile teams currently serving primary care clinics on a weekly basis
will eventually be phased out and replaced by fully integrated teams ofhealth workers based permanently at the primary care level. The MoH is
not expected to maintain this complex, unsustainable, resourceintensive model of care delivery; instead, services provided by themobile outreach teams will be gradually integrated into primary careclinics on a permanent basis.

Photo © James Oatway

Drug resistance is a growing problem in Swaziland, as indicated by the
recent drug sensitivity testing survey. Although progress has been madein improving DR-TB management, current national diagnostic andtreatment capacity is still inadequate to cope with the suspected number
of DR-TB patients. Boosting capacity through better training for healthworkers, routine drug sensitivity screening, improved drug supply andeasy access to treatment via community treatment supporters are
essential components of an improved model of DR-TB care.

Building national healthcare capacity

A bedridden MDR-TB patient is surrounded by relatives at his homestead. Adapted home-based care and avoiding transmission to others are key priorities

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Conclusion and recommendations
Experience from Shiselweni demonstrates the safety
and effectiveness of a decentralised, integrated
approach to care that caters to patients' needs. Since
the programme began, the number of patients being
tested and initiated on TB treatment and ART hassignificantly increased, as has retention in care.
Much of the success of this model of care delivery lies
in task shifting as an effective way of managing thenational health crisis with limited financial and humanresources. By using trained and supervised lower
cadre health workers to provide widespread access to
HIV and TB care, the MoH and MSF have succeeded in
keeping care within the community and tapping into
the growing resource of expert clients with direct
experience and knowledge of HIV, TB and related
issues. Existing healthcare staff also acknowledge thebenefits of this approach: by delegating tasks, nurses
are freed up to do clinical work (which they frequently
find both valuable and satisfying); staff are also
supported in meeting the growing burden of carerelated to HIV and TB; and they have access toexpertise in TB and HIV diagnosis and counselling.
However, task shifting will not be embraced by all
unless it is anchored in a regulatory framework.
Even more importantly, the decentralisation ofservices has also dramatically improved patient
access to care and treatment. Instead of making longand expensive journeys to the region's health facilities,
many patients now have access to integrated HIV and
TB services nearer to home – a positive development
which is clearly reflected in higher retention in care.
Giving DR-TB patients the option to receive injectables
at home during the intensive phase of treatment isanother major step forward in adapting care to meetpatients' needs and support treatment adherence.
Generally, the integration of TB and HIV care andtreatment at primary, secondary and tertiary levels
should come as a direct result of joint planning andbudgeting by the ART and national TB control
programmes. Indeed, one HIV/TB integrated national
programme would go a long way to ensuringcontinuity and consistency in the delivery of adapted
services at all levels.

Improved infection control measures have madehealthcare environments safer for both staff andpatients, and are encouraging safer homeenvironments for patients. Intensive case finding
among HIV patients at all clinics is also improving
infection control in the community by identifying TB
patients and starting them on treatment earlier.
The implementation of new diagnostic techniques atboth rural and central levels is also an important step
forward in boosting the national capacity to cope with agrowing number of patients, in particular given efforts
to increase HIV testing and TB case finding. It also aims
to ensure early diagnosis and treatment of both TB andHIV. The sample transportation service MSF is running
throughout Shiselweni is also helping to ensure a fast
turnaround of diagnosis and allowing healthcare
workers to start patients on the appropriate treatment
as soon as possible. The current transportation systemshould be taken over by the MoH.
These are important steps forward, yet major
challenges still lie ahead. The new health cadres
advocated by MSF must be absorbed into the MoH
health system, while existing health workers must be
educated to accept these new functions, and patients
must have access to information about the services
available to them, if the country is to benefit from thedecentralised approach to care. Laboratory capacity
must be further strengthened to cope with the
projected increase in people with HIV in need of ART
and the growing number of TB and DR-TB patients.
The bureaucracy that dominates management of thenational drug supply must be phased out and replacedwith a well-functioning standardised system thatguarantees drug delivery on time and prevents drug
stock-outs with devastating consequences forpatients. Finally, care must be fully decentralised to all
health facilities in Shiselweni region to remove thegeographical and financial barriers to TB and HIV
treatment that many patients still face.
In a context where the HIV/TB co-epidemic threatens towipe out generations of Swazis, translating politicalcommitment into further practical action is moreurgent than ever.

Photo © Jonathan Heyer