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MSF in Swaziland, 2011
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Swaziland is struggling with a dual epidemic of HIV/AIDS and tuberculosis (TB). The scale-up of treatment has been made even more difficult by a national financial crisis.
Throughout 2011, there were strikes and demonstrations, and the government had difficulties securing funds to buy drugs and supplies to respond to the national HIV emergency. Thousands of lives are affected. Almost 26 percent of adults aged between 15 and 49 have HIV. At any one time, four in 10 pregnant women are HIV positive. Some 80 percent of TB patients are co-infected with HIV.
HIV and TB care in Shiselweni
Swaziland is a rural country with many small, isolated villages. Health centers are often far from people’s homes, making journeys for medical attention long and expensive.
Shiselweni, in the south, is the poorest and most remote region. Since 2007, Doctors Without Borders/Médecins Sans Frontières (MSF) teams have been focusing on facilitating free access to HIV and TB services at the closest point of care. Today, 22 rural clinics in Shiselweni offer HIV and TB care. This means that people with both diseases can receive all their treatment at their local health center. More than 2,000 patients are treated for TB every year, and at the end of 2011, 18,000 patients were receiving antiretroviral (ARV) treatment.
In 2011, MSF introduced new staff, based in the community, who offer testing and counseling. They now work in every clinic, and since the scheme started, the number of people tested has more than tripled, to over 2,300 per month.
In addition, MSF works in a health center in the town of Matsapha, in central Swaziland, where 378 people received treatment for TB and 705 patients are on ARV treatment. Staff also offer comprehensive healthcare to local workers – holding consultations outside of working hours so that textile workers can see medical staff.
In Mankayane, not far away, the MSF team assisted Ministry of Health staff in improving the diagnosis and treatment of 664 patients co-infected with HIV and TB, and treated 60 patients with drug-resistant tuberculosis (DR-TB).
New DR-TB facilities
The management of DR-TB is a growing challenge in Swaziland. DR-TB can be caught from someone with the disease, but can also develop when a person with TB grows resistant to standard treatment. The treatment regime for DR-TB is very difficult, and causes a range of side effects. Patients receive daily injections for at least six months, and have to take as many as 18 pills a day for up to two years. Almost eight percent of new TB cases are drug-resistant.
MSF supported the National Reference Laboratory for Tuberculosis in carrying out diagnoses. At the end of 2011, 172 people were being treated for DR-TB in the region of Shiselweni alone. In September, a new DR-TB ward, built by MSF, was inaugurated in Nhlangano, in the presence of King Mswati III. Nhlangano is a large town in the south of the country. The ward complements the community-based approach to treatment by offering inpatient care to those who are very sick closer to home. It is run by the Ministry of Health and MSF teams together.
Eleven rural clinics were also rehabilitated. They were fitted out with new, well-ventilated waiting areas and additional consultation rooms.
In Matsapha and Mankayane, MSF introduced a new TB testing machine, which significantly reduces the time it takes for diagnosis, and which can test for some forms of drug resistance.
Task-shifting to go national
Very few Swazi medical doctors are working in public health outside of the capital Mbabane, and many who train in the country leave for places where employment conditions are better. A lack of medical human resources is recognised as the main obstacle to expanding health service capacity.
MSF uses task-shifting in its programs to enable more people to receive care. Nurses, rather than doctors, are trained to initiate ARV treatment, or administer drugs for uncomplicated, non-resistant TB, while counselors are taught how to test people for HIV, thus freeing up nurses for other work.
In 2011, the Ministry of Health began developing a national framework for task-shifting, which should significantly increase staff capacity across the country.
Shortages of medicines
Although the HIV and TB epidemics have been declared emergencies in Swaziland, MSF contingency stocks of ARV drugs had to be used by thousands of patients in 2011 due to shortages in national stocks. MSF appealed to King Mswati III to make sure all measures are taken to guarantee the timely procurement, supply and distribution of drugs and laboratory supplies to health facilities and patients.
At the end of 2011, MSF had 246 staff in Swaziland. MSF has been working in the country since 2007.