Leveraging HIV care systems to improve cardiovascular disease prevention in the Kingdom of eSwatini

ABSTRACT/SUMMARY
ESwatini has the world’s highest prevalence of HIV, with more than one in four adults currently living with HIV.
Extraordinary efforts at reducing the burden of HIV/AIDS have led eSwatini to become the first African country
to surpass the UNAIDS “95-95-95” goals of diagnosing ≥95% of people living with HIV (PLHIV), providing
treatment to ≥95% of those diagnosed, and achieving viral load suppression in ≥95% of those on treatment,
leading to dramatic reductions in HIV mortality. In contrast, deaths from many non-communicable diseases
(NCDs) in eSwatini are increasing. Deaths from cardiovascular disease, the second-leading cause of death
after HIV/AIDS in eSwatini, have risen by 11% since 2000. Deaths from cancer, diabetes, chronic kidney
disease, self-harm, and violence have increased by 12-35% over the same time period. Accordingly, the
eSwatini Ministry of Health (MoH) is keenly interested in leveraging HIV care systems to improve care and
prevention for cardiovascular disease and other high-burden NCDs. Due to resource constraints, not all NCD
care can be provided to all residents of eSwatini, but a health benefits package (HBP) could be created to
deliver the greatest possible health benefits within the limits of the country’s health budget and cadre of
healthcare personnel. Additionally, like many other countries, eSwatini faces a growing risk of pandemics,
conflict, and natural disasters due to population growth and climate change. These events can cause
exogenous shocks that interrupt routine healthcare delivery, which may have implications for prioritizing which
health services to offer. For example, investments in primary prevention may become a more efficient option
than continuously delivering treatment for diseases when taking into consideration the likelihood of exogenous
shocks to the healthcare system over coming decades. Our team combines expertise in modeling, health
economics, HIV/NCD care integration, and eSwatini’s health system – including the current Director of
Planning for the eSwatini Ministry of Health. Our study will (Aim 1) determine which non-HIV health services
will be efficient to co-deliver with HIV care given the evolving demographics and health risks among people
living with HIV in eSwatini, (Aim 2) determine which services to include in eSwatini’s HBP to maximize
population health under resource constraints, and (Aim 3) assess trade-offs between health system efficiency
and resilience to exogenous shocks such as pandemics, conflict, and natural disasters. Additionally, eSwatini
is likely to be a forerunner of health policy questions to arise elsewhere in sub-Saharan Africa, where other
countries are working to surpass the “95-95-95” treatment goals in coming years. Accordingly, we will
disseminate results in the Eastern, Central, and Southern Africa Health Community to amplify the impact of our
research and set the stage for future work.

Grant Number: 5R01HL169021-03
NIH Institute/Center: NIH
Principal Investigator: Anna Bershteyn