By Lenhle Dube, National HTS Coordinator, Eswatini National AIDS Programme, Ministry of Health, Eswatini, and Pido Bongomin, Chief Technical Officer and Deputy Country Resident Director, Georgetown University, Center for Global Health Practice and Impact, Eswatini
Eswatini has recorded significant success in scaling up differentiated HIV testing to identify individuals and populations with increased HIV vulnerability. The 2021 Eswatini Population-based HIV Impact Assessment (PHIA) indicated that 94% of people aged 15 years and older living with HIV were aware of their HIV status. This improved to 97% in 2024 (Ministry of Health data). However, lingering case-finding gaps remain at the sub-population level, including among children 15 years and below, women aged 15-24 years, men aged 25-34 years, the military and key populations.
To close the remaining HIV testing service (HTS) gaps and maximize HTS reach and coverage at health facility entry points, the Eswatini National AIDS Programme (ENAP) implemented strategic shifts in HTS implementation. These included: replacement of the HIV Risk Screening Tool with HIV self-testing (HIVST) for triage in outpatient departments OPDs; lowering the HIVST age of consent from 16 to 12 years; and adopting a status-neutral approach to HIV testing, care and prevention. These shifts are aligned with the PEPFAR COP23 guidance and the WHO 2024 Consolidated guidelines on differentiated HIV testing services. With increasingly limited programme funding for HTS and limited human resources available to provide HIV testing services, these strategic shifts were crucial to optimize testing coverage and reduce wait times.
NAP, with support from CDC/PEPFAR through Georgetown University, developed a standard operating procedure for HIVST, including a process flow for using HIVST as an OPD screening/triage tool. Following a needs assessment, all HTS providers received refresher training on how to conduct, confirm and document HIVST. To address the need for additional space and client privacy, 35 high-volume facilities were provided with HIVST booths to promote unassisted HIVST on site, reducing the workload of providers and costs to the health system. Another 22 booths were placed strategically at community testing points. A further 60 testing booths are being requisitioned, with support from the Global Fund.
Through these interventions, we were able to demonstrate near-universal testing coverage in OPD, with a three-fold increase in case finding. Unfortunately, our earlier success could not be sustained due to Eswatini’s supply chain woes in the past year. Optimization will continue once sufficient quantities of HIVST kits are restored.
