Opportunities for improved HIV prevention and treatment through budget optimization in Eswatini

Abstract

Introduction Eswatini achieved a 44% decrease in new HIV infections from 2014 to 2019 through substantial scale-up of testing and treatment. However, it still has one of the highest rates of HIV incidence in the world, with 14 infections per 1,000 adults 15-49 years estimated for 2017. The Government of Eswatini has called for an 85% reduction in new infections by 2023 over 2017 levels. To make further progress towards this target and to achieve maximum health gains, this study aims to model optimized investments of available HIV resources. Methods The Optima HIV model was applied to estimate the impact of efficiency strategies to accelerate prevention of HIV infections and HIV-related deaths. We estimated the number of infections and deaths that could be prevented by optimizing HIV investments. We optimize across HIV programs, then across service delivery modalities for voluntary medical male circumcision (VMMC), HIV testing, and antiretroviral refill, as well as switching to a lower cost antiretroviral regimen. Findings Under an optimized budget, prioritising HIV testing for the general population followed by key preventative interventions may result in approximately 1,000 more new infections (2% more) being averted by 2023. More infections could be averted with further optimization between service delivery modalities across the HIV cascade. Scaling-up index and self-testing could lead to 100,000 more people getting tested for HIV (25% more tests) with the same budget. By prioritizing Fast-Track, community-based, and facility-based antiretroviral refill options, an estimated 30,000 more people could receive treatment, 17% more than

Individual and community-level factors associated with lifetime number of sexual partners among women aged 15–49 in Eswatini

“…Some public health experts believe that multiple concurrent partnerships and high partner acquisition are the main drivers of the persistent and high incidence of HIV in Sub-Saharan Africa (SSA) [ 19 , 20 ]. Evidence suggests that multiple sexual partners during acute HIV infection are a driving force in heterosexually transmitted HIV epidemics in SSA, including Eswatini [ 6 , 21 – 23 ]. Multiple sexual partnerships coupled with inconsistent condom use increase the risk of HIV acquisition [ 3 , 23 ].…”

Comparative Clinical Outcomes With Scale-up of Dolutegravir as First-Line Antiretroviral Therapy in Ukraine

“…A modeling study in Eswatini estimated that switching to use of DTG-based regimens for all first-line treatment among nonpregnant adults would save approximately 4% of the national budget for all HIV programs, with potential to reallocate this funding for further ART scale-up or for HIV prevention activities. 6 The rationale for Ukraine's ART Optimization Initiative included an assumption that costs of ART scale-up could be offset by the cost-savings of increased use of DTG. In May 2017, when DTG was first introduced in Ukraine, there were 81,773 patients on ART nationally.…”

“…To reach UNAIDS targets for HIV epidemic control globally, including the target that 90% of all patients on HIV antiretroviral therapy (ART) achieve HIV viral suppression (VS), 1 it is important to have first-line ART regimens that are easy to use, well-tolerated, and efficacious. Dolutegravir (DTG) is an integrase strand reverse transcriptase inhibitor with a favorable effectiveness, tolerability, [2][3][4][5] and cost 6 compared with several common first-line regimens. In 2017, the World Health Organization (WHO) and the President's Emergency Plan for AIDS Relief embraced global rollout of the fixed dose regimen of tenofovir, lamivudine, and dolutegravir.…”

Approaches to improving the efficiency of HIV programme investments

“…Optima (hiv.optimamodel.com), a dynamic population-based compartmental model, has been used to model optimisation of investments of available HIV resources 7–9. Studies suggest that the optimal distribution of HIV resources depends on the available HIV budget and the characteristics of each country’s epidemic, response and targets.…”

“…com), a dynamic population-based compartmental model, has been used to model optimisation of investments of available HIV resources. [7][8][9] Studies suggest that the optimal distribution of HIV resources depends on the available HIV budget and the characteristics of each country's epidemic, response and targets. However, scaling up focused testing and antiretroviral therapy (ART) was found to be an efficient use of resources in nearly all settings.…”