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

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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.