Outcomes and impact of HIV prevention, ART and TB programs in Swaziland--early evidence from public health triangulation.
BACKGROUND
Swaziland's severe HIV epidemic inspired an early national response since the late 1980s, and regular reporting of program outcomes since the onset of a national antiretroviral treatment (ART) program in 2004. We assessed effectiveness outcomes and mortality trends in relation to ART, HIV testing and counseling (HTC), tuberculosis (TB) and prevention of mother to child transmission (PMTCT).


METHODS
Data triangulated include intervention coverage and outcomes according to program registries (2001-2010), hospital admissions and deaths disaggregated by age and sex (2001-2010) and population mortality estimates from the 1997 and 2007 censuses and the 2007 demographic and health survey.


RESULTS
By 2010, ART reached 70% of the estimated number of people living with HIV/AIDS with CD4<350/mm(3), with progressively improving patient retention and survival. As of 2010, 88% of health facilities providing antenatal care offered comprehensive PMTCT services. The HTC program recorded a halving in the proportion of adults tested who were HIV-infected; similarly HIV infection rates among HIV-exposed babies halved from 2007 to 2010. Case fatality rates among hospital patients diagnosed with HIV/AIDS started to decrease from 2005-6 in adults and especially in children, contrasting with stable case fatality for other causes including TB. All-cause child in-patient case fatality rates started to decrease from 2005-6. TB case notifications as well as rates of HIV/TB co-infection among notified TB patients continued a steady increase through 2010, while coverage of HIV testing and CPT for co-infected patients increased to above 80%.


CONCLUSIONS
Against a background of high, but stable HIV prevalence and decreasing HIV incidence, we documented early evidence of a mortality decline associated with the expanded national HIV response since 2004. Attribution of impact to specific interventions (versus natural epidemic dynamics) will require additional data from future household surveys, and improved routine (program, surveillance, and hospital) data at district level.
The South African Department of Science and Technology / National Research Foundation Centre of Excellence in Epidemiological Modelling and Analysis, University of Stellenbosch, Cape Town, South Africa. carivs@sun.ac.za
Cari
C
van Schalkwyk
Sibongile
S
Mndzebele
Thabo
T
Hlophe
Jesus Maria
JM
Garcia Calleja
Eline L
EL
Korenromp
Rand
R
Stoneburner
Cyril
C
Pervilhac
D000293:Adolescent; D000328:Adult; D023241:Antiretroviral Therapy, Highly Active / Q000706:statistics & numerical data*; D002423:Cause of Death; D015897:Comorbidity; D003376:Counseling; D013541:Eswatini / Q000453:epidemiology; D005260:Female; D015658:HIV Infections / Q000150:complications / Q000188:drug therapy* / Q000453:epidemiology / Q000517:prevention & control*; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D015994:Incidence; D018445:Infectious Disease Transmission, Vertical / Q000517:prevention & control; D007297:Inpatients; D008297:Male; D008875:Middle Aged; D009313:National Health Programs / Q000706:statistics & numerical data*; D015995:Prevalence; D011634:Public Health / Q000706:statistics & numerical data*; D016019:Survival Analysis; D016896:Treatment Outcome; D014376:Tuberculosis / Q000150:complications* / Q000453:epidemiology / Q000517:prevention & control*; D055815:Young Adult