Max ART - Final Report Phase 1

“The vision of Max ART is to reach all people in Swaziland who are in need of treatment with an ultimate goal of preparing the country for the possibility of ending the HIV epidemic that will be exemplary for the Southern African region.”

This report provides an overview of phase 1 of the Maximizing ART for Better Health and Zero New HIV Infections (MaxART) project, which seeks to improve the lives of people living with HIV and prevent new HIV infections in Swaziland. Implemented by STOP AIDS NOW! and partners, the project hopes to "catalyse a fundamental shift in the way the international community approached the HIV epidemic. They wanted to test a new and bold approach with virtual elimination of new infections, even in the most difficult of circumstances. Swaziland, the country with highest prevalence of HIV in the world, was selected as the country to test if this dream could come true." The first phase (2011-2015) of MaxART supported a number of interventions and systems strengthening activities aimed at achieving universal access to HIV treatment and to improve the health of the people of Swaziland. This publication reports on the strategies and results of the first phase, and highlights some of the key reasons for the success of the project.

As explained in the report, Max ART has three goals:

1. Achieving universal access to testing and treatment in Swaziland - seeking to target the remaining gaps and key barriers to reaching all those individuals who are in need of HIV testing and treatment, significantly increase the pace at which patients are enrolled into care and treatment, and retain all patients who are on ART.
2. Assessing the impact of universal access to testing and treatment on prevention efforts - focused on assessing and addressing key barriers and understanding the needs and realities of people living with HIV from a human rights perspective. Social science research collected evidence on how to maximise the quality and utilisation of HIV testing and counselling and evaluated the factors influencing adherence to ART. It also assessed the needs and realities of people living with HIV using the Positive Health Dignity and Prevention framework.
3. Demonstrating treatment as an effective form of prevention in a high-prevalence setting - proving the concept of Treatment as Prevention.

The report looks at the first two goals of the project which formed part of phase 1 and highlights the different strategies and activities used, as well as the results for each activity. The activities are either community-level interventions or health-facility-level interventions and can briefly be listed as follows:

Mobilise communities:

• Strengthen community mobilisation through Community Based Volunteers (CBVs)
• Engage traditional leadership
• Male-focused health days
• Adolescent support initiative
• Demand Creating Community Dialogues
• Campaigns and advocacy

HIV Testing:

• Strengthen provider-initiated testing and counselling
• Fast-track community solutions to mobilising men and adolescents for testing

Enrolment in Care:

• Point of care (POC) CD4 testing
• Strengthening treatment support
• Improved linkages, including referral systems

ART initiation:

• Nurse-led ART initiation
• Strong adherence counselling
• Improved laboratory services (sample transportation)
• Strong supply chain system

Retention in Care:

• SMS (short message service) appointment reminder system
• Treatment support
• Linkages with community health workers
• Reduced stigma through initiatives by people living with HIV (PLHIV)

In addition to the above, the programme advocated for change of policies and strategies within the Swaziland context. For example, the age of consent for HIV testing was reduced and taken forward in the revised HIV testing guidelines. Also, Max ART emphasised learning from experience and critically assessing and revising interventions along the way. This was done through biannual face-to-face meetings with all the partners, presenting the work of Max ART at national and international conferences, and publishing results and findings of the programme in peer-reviewed journals (the full list is given in the Appendix of the report).

In terms of results, the report states that "[O]ver the past three years of implementation of Max ART, Swaziland has made great progress towards reaching the overarching objectives to (i) test at least 250,000 people annually, (ii) ensure 90% of those eligible for treatment are on treatment, and (iii) retain 90% of all clients in care each year by 2014." The following are just a selection of activities and their results related to the community-focused interventions outlined above, which are highlighted here because of their communication focus:

Community mobilisation through door-to-door visits - Community Based Volunteers (CBVs) or Rural Health Motivators (RHMs) conduct door-to-door visits to mobilise individuals for HIV testing and to motivate PLHIV to take antiretrovirals (ARVs) and to adhere to their treatment. PLHIV on ART were also educated on treatment and side effects and other health problems. As stated in the report, a total of 5,761 RHM/CBVs were trained over the 3 years on the Max ART topics, and refresher training was done as well. Monitoring and evaluation (M&E) reports indicate that 95% of the RHMs/CBVs remained active over the 3 years. If each of these volunteers covers about 50 households, they would reach about 288,000 households.

Community mobilisation through community dialogues - The objective of this intervention was to increase access to HIV-related services by discussing community barriers to service uptake and having communities find solutions by themselves. The report highlights that during phase 1, 269 Demand Creating Community Dialogues (DCCDs) were held in 220 communities with over 28,300 people attending, of whom 56% were men. The dialogues were very well attended, with 70-100 people present each time. Almost 50% of the attendees were tested for HIV.

Engagement of traditional and political leaders - In 2011, a total of 98 traditional leaders and 12 political leaders were trained in 33 chiefdoms (in 31 constituencies) in all regions of the country. Many of these leaders became actively engaged in stimulating the HIV response within their communities. Traditional leaders have been participating in the annual Indabas, and several communities report about the HIV response through the traditional leaders.

Male Focused Health Days (MFHDs) - Men gathered for discussions around health and HIV topics and were encouraged to test for HIV, which was offered on site. The days were meant to create greater comfort and stronger relationships between men and their local health facility. Implemented in 15 clinics in Swaziland, the results show that over the 3-year period, 500 HIV tests were done during 180 events, which included 6,057 participants. Out of the 15 clinics, 6 were more successful than the others, and some of these continued implementation without direct Max ART support. In these 6 clinics, there was a significant increase of men being tested for HIV per month. Prior to MFHDs, on average, 13 men tested for HIV per month, which went up to 30 men per day towards June 2014.

The Adolescent Support and HIV Testing and Counselling initiative - This activity focused on strengthening and establishing support structures for youth, with the goal of incorporating testing opportunities into its activities. According the report, the number of adolescents testing for HIV directly through teen club events has increased since the start of the intervention. A total of 982 HIV tests were conducted as of June 2014, and a total of 7,923 adolescents attended teen clubs (including repeat attendees, which are on average 30% of total attendance).

Campaigns and advocacy - Max ART, together with other in-country implementing partners designed a media campaign called “My health starts with me”. Both TV and radio shows talked about HIV in general, HIV testing, treatment, etc. There were 52 episodes on different topics on TV and many more radio shows with an estimated 2,500 listeners per radio slot and 1,500 viewers of each TV show. The shows were popular, and several respondents in the community highlighted that these shows mobilised them to seek care in the clinics.

The second goal of the project involved social science research studies of the Max ART programme. The research focused on men and adolescents who are two hard-to-reach groups, both for accessing HIV testing and ART services, in order to better understand the reasons why these groups were not accessing health services.

The report highlights some of the key reasons for the success of the project. The following are just a selection:

• Working with civil society and other partners - over the years, the consortium invested in strengthening collaboration and ensured that the voice of civil society was heard. Specific efforts were made to decrease the natural tendency of partners to work in silos and improve coordination from geographical perspectives to improve impact of our work.
• Strong leadership of the Ministry of Health (MoH) - the Ministry constantly monitored progress and adjusted national strategies based on the learning of the programme as and when required.
• Strong involvement of the network of PLHIV - this ensured that interventions were designed in such a way that the needs and rights of PLHIV were respectfully addressed and thus the principles of Greater Involvement of People Living with HIV and AIDS (GIPA) were operationalised.
• Recognition of the importance of community mobilisation and demand creation - both are now well established in Swaziland, both in the MoH and in the National Emergency Response Council on HIV and AIDS (NERCHA). MoH has partnered with key non-government organisations (NGOs) specialising in community mobilisation, and a Technical Working Group was set up to address these issues.
• Basing activities on social science research - the research provided important insights about the groups intended to be reached (men and adolescents) and the health and community systems barriers to access, which were, where possible, addressed in the interventions. The team believes that the policy influence of some of the research outcomes was strongly influenced by the embeddedness of the research in a multidisciplinary programme, in which implementers, policymakers, and researchers work together towards shared goals.