HIV PROGRAMMING IN ESWATINI - Geographic and Programmatic Scoping for Adolescent Girls and Young Women - UNICEF

 
HIV PROGRAMMING IN ESWATINI - Geographic and Programmatic Scoping for Adolescent Girls and Young Women - UNICEF
KINGDOM OF ESWATINI

Geographic and Programmatic Scoping
for Adolescent Girls and Young Women
HIV PROGRAMMING IN ESWATINI
HIV PROGRAMMING IN ESWATINI - Geographic and Programmatic Scoping for Adolescent Girls and Young Women - UNICEF
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Copyright: Eswatini Ministry of Health
Publication year: 2019
HIV PROGRAMMING IN ESWATINI - Geographic and Programmatic Scoping for Adolescent Girls and Young Women - UNICEF
KINGDOM OF ESWATINI

Geographic and Programmatic Scoping
for Adolescent Girls and Young Women
HIV PROGRAMMING IN ESWATINI
HIV PROGRAMMING IN ESWATINI - Geographic and Programmatic Scoping for Adolescent Girls and Young Women - UNICEF
Acknowledgments

Acknowledgements
I would like to express my gratitude to UNICEF staff, especially Leonard Kamugisha, to the Global Fund, specifically
Alexandra Plowright, and to Nqobile Tsabedze, Nomathemba, Lungile Tshabalala, and Lungile Nkambule at CANGO
for their guidance and support on the development of the Consolidated Report. An appreciation is also extended to
the key informants and focus group participants who made time to discuss areas of interest to the scoping exercise.
The consultative meetings throughout the document development phase set a good foundation for the geographic
and programmatic scoping for adolescent girls and young women, HIV programming in the Kingdom of Eswatini.

Lastly, I would like to thank the data collectors who collected data in Mahlangatja, Mhlume and SomntongoTinkhundla.

Documentation by:

Dr. Nyasha Madzingira
Independent Consultant
Mobile: +263-773061807
        +263-712203745
Skype: dr.nyasha
Email: nyasha.madzingira@gmail.com
HIV PROGRAMMING IN ESWATINI - Geographic and Programmatic Scoping for Adolescent Girls and Young Women - UNICEF
Table of Contents
CONTENTS

Foreword                                                     vii
    Abbreviations and Acronyms                                vii

A. BACKGROUND AND CONTEXT                                     1

 1. Introduction                                              1
    1.1   Purpose                                              1
    1.2   The CANGO Programme                                  1
    1.3   Methodology                                          3
    1.4   Limitations to the Scoping Exercise                  4

 2. Global and Subregional HIV Situation                      5
 3. Global, Regional- and Country-Level Policy Environment    7
    3.1   Commitments at Global Level                          7
    3.2   Continental and Regional Policies and Strategies     9
    3.3   Eswatini HIV and AIDS Policy Environment            11

B. NATIONAL GEOGRAPHIC AND |
   PROGRAMMATIC SCOPING OF AGYW                              14

 4. Statistical Snapshot                                     14
 5. Programme Results                                        16
 6. Intervention Mapping                                     16
 7. Coordination                                             23
 8. Key Global Investments                                   24

                                                                    v
HIV PROGRAMMING IN ESWATINI - Geographic and Programmatic Scoping for Adolescent Girls and Young Women - UNICEF
C. GEOGRAPHIC AND PROGRAMMATIC SCOPING
        OF AGYW IN 3 TINKHUNDLA                                           26

      9. Statistical Snapshot of the Three Tinkhundla                     26
      10. Socioeconomic Environment                                       27
          10.1 Living Arrangements for AGYW                               27
          10.2 HIV and AIDS                                               28
          10.3 SRH and HIV and AIDS Services                              31
          10.4 Education                                                  34
          10.5 Gender-based Violence Response                             36
          10.6 Civil Society Organizations                                37

      11. Economic Empowerment Programmes for AGYW                        39
      12.Community Structures and Systems for HIV Prevention among AGYW   41

     D. CHALLENGES                                                        42

      13. Challenges/Gaps                                                 42
          13.1 Overall                                                    42
          13.2 Constraints Faced by AGYW                                  43
          13.3 Challenges Faced by ABYM                                   44

     E.   RECOMMENDATIONS                                                 45

      ANNEXES                                                             47
          Annex 1. Documents Reviewed                                     47
          Annex 2: List of Key Respondents                                50
          Annex 3: Mahlangatja Clinic Checklist                           52

vi
HIV PROGRAMMING IN ESWATINI - Geographic and Programmatic Scoping for Adolescent Girls and Young Women - UNICEF
BACKGROUND AND CONTEXT
                                                                                 A

Abbreviations and Acronyms
Foreword
ABYM		     Adolescent boys and young men
AG		       Adolescent girls
AGYW		     Adolescent girls and young women
AIDS		     acquired immunodeficiency syndrome
ART		      antiretroviral treatment
ASRH 		    adolescent sexual and reproductive health
AU		       Africa Union Commission
BSRCS		    Baphalali Eswatini Red Cross Society
CANGO		    Coordinating Assembly of Non-governmental Organizations
CBO		      Community-based Organization
CDC		      Centers for Disease Control and Prevention
CHAPS		    Centre for HIV and AIDS Prevention Studies
CHIPS		    Children’s Intervention in Swaziland
COMM ART   Community-centred models of ART
COP		      Country Operational Plan
CSE		      Comprehensive sexuality education
CSO		      Central Statistical Office
CSTL		     Care and support for teaching and learning
DHS		      Demographic and Health Survey
DREAMS     Determined, Resilient, Empowered, AIDS-free, Mentored and Safe
EGPAF		    Elizabeth Glaser Pediatric AIDS Foundation
ESA		      Eastern and southern Africa
ESAR		     Eastern and southern Africa region
FGDs		     Focus group discussions
FLAS		     Family Life Association of Eswatini
GBV		      Gender-based violence
GF		       Global Fund
GKoE		     Government of the Kingdom of Eswatini
HIV		      human immunodeficiency virus
HSS		      Health system strengthening
HTC		      HIV testing and counselling
HTS		      HIV testing services
IEC		      Information, education and communication
IPPF		     International Planned Parenthood Federation
LSE		      Life-skills education
MDR-TB		   Multi-drug-resistant tuberculosis
MICS		     Multiple Indicator Cluster Survey
MITC		     Manzini Industrial Training Centre
MOH		      Ministry of Health
MSF		      Médecins Sans Frontières
MSM		      Men having sex with men

                                                                                     vii
HIV PROGRAMMING IN ESWATINI - Geographic and Programmatic Scoping for Adolescent Girls and Young Women - UNICEF
NaHSAR     National HIV Semi- Annual Review
       NATICC		   Nhlangano AIDS Training Information and Counselling Centre
       NERCHA     National Emergency Response Council on HIV and AIDS
       NFM 1		    New Funding Model 1 Cycle from 2014 to 2016
       NGO		      Non-governmental organization
       NSF		      National Strategic Framework for HIV and AIDS
       OVC		      Orphans and vulnerable children
       PEP		      Post-exposure prophylaxis
       PEPFAR		   President’s Emergency Plan for AIDS Relief
       PLHIV		    People living with HIV
       PMTCT		    Prevention of mother-to-child transmission
       PrEP		     Pre-exposure prophylaxis
       PSI		      Population Services International
       RA		       Research Assistant
       REC		      Research Ethics Committee
       RSSC		     Royal Swaziland Sugar Company
       SADC		     Southern Africa Development Community
       SANU		     Southern Africa Nazarene University
       SBCC		     Social behaviour change communication
       SGBV		     Sexual and gender-based violence
       SHIMS 2    Eswatini HIV Incidence Measurement Survey 2
       SMS		      Short message service
       SNAP		     Eswatini National AIDS Programme
       SRH		      Sexual and reproductive health
       SRHR		     Sexual and reproductive health and rights
       STI		      Sexually transmitted infections
       SWAGAA     Eswatini Action Group Against Abuse
       TA		       Technical assistance
       TB		       Tuberculosis
       TFFC		     Taiwan Fund for Children
       TOR		      Terms of Reference
       UN		       United Nations
       UNAIDS		   Joint United Nations Programme on HIV and AIDS
       UNESCO     United Nations Educational, Scientific and Cultural Organization
       UNFPA		    United Nations Population Fund
       UNGASS     United Nations General Assembly Special Session
       UNICEF		   United Nations Children’s Fund
       USAID		    United States Agency for International Development
       VH		       Viral hepatitis
       VLS		      Viral load suppression
       VMMC		     Voluntary medical male circumcision
       WFP		      World Food Programme
       WHO		      World Health Organization
       YM		       young men
       YW		       young women

viii
HIV PROGRAMMING IN ESWATINI - Geographic and Programmatic Scoping for Adolescent Girls and Young Women - UNICEF
BACKGROUND
AND CONTEXT                                                                                           A.
1. Introduction
1.1         Purpose
UNICEF Eswatini Country Office commissioned an assignment entitled ‘Geographic and Programmatic Scoping for
Adolescent Girls and Young Women HIV Programming in Three Constituencies/Tinkhundla in Eswatini’. The assignment
was divided into two main areas of work, the first being a comprehensive literature review to be complemented by
key informant interviews on the status of HIV and adolescent girls and young women with respect to: a) policy; b)
funding and; c) programming in the country.

The second was the scoping of three constituencies (namely Mahlangatja in Manzini Region; Mhlume in Lubombo
Region and Somthongo in Shiselweni Region) in support to CANGO (Coordinating Assembly of NGOs) which is a
Global Fund Principal Recipient and will be initiating a programme for adolescent girls and young women (AGYW) in
the three Tinkhundla from October 2018. The scoping addressed the following objectives:

   i.      Determine HIV, health, education, social services, gender-based violence (GBV) response, justice/police,
           community-based organizations based in the relevant geographical areas and their scope of work;
   ii.     Assess existence of income-generating projects/initiatives involving AGYW;
   iii.    Determine social/economic engagements of AGYWs (what occupies their time); and
   iv.     Assess the extent to which there is a community support system that enables AGYW to access HIV and
           sexual and reproductive health- (SRH) related services.

This Consolidated Report is the deliverable for the both parts of the assignment.

1.2         The CANGO Programme
CANGO has been receiving funding from the Global Fund since 2016 as Principal Recipient representing civil society.
This funding is mainly for an HIV prevention programme and is further distributed to sub-recipients who directly
implement the programmes while CANGOs role is mainly around the management of the grant and the provision
of technical support and guidance. A community programme designed for out-of-school youth is offered in 20
constituencies. The overall goal of the programme is to halt the spread of HIV and reverse its impact in Eswatini
society.

A special programme for AGYW aged 10–24 years is implemented in three high density, low income constituencies
namely; Somntongo, Mahlangatja and Mhlume from the Shiselweni, Manzini and Lubombo regions, respectively. This

                                                                                                                      1
programme has two layers, the first layer is the Stepping Stone sessions which provide HIV prevention education and
    distribution of condoms. These sessions also act as basis to identify beneficiaries who qualify and are willing to be a
    part of the second layer, namely economic strengthening and education support.Through the economic strengthening,
    beneficiaries are taken through the WORTH Programme which is believed to provide economic freedom to the AGYWs,
    while the education support comes in the form of secondary education subsidies which are paid directly to the school.
    The expected immediate outcomes for these programmes are improved knowledge around HIV Testing Services (HTS)
    and increased service uptake for HTS and Sexual and Reproductive Health (SRH) while the long-term objective is the
    reduction of new HIV infections among AGYW by 2022.

        Two sub-recipients (World Vision and Young Heroes) are responsible for the implementation of this programme and
    the target is to support 500 individuals with the education subsidies throughout the three years (2018−2021), 4000
    individuals per year with the Stepping Stone sessions and 420 individuals/members for the WORTH groups. Other
    innovations include activities i which provide HTS services for youth. A similar programme for the New Funding
    Model 1 Cycle from 2014 to 2016 (NFM 1), which has been under implementation between 2016 and 2018, provided
    only one layer, which is the Stepping Stone session in 20 constituencies.

    The CANGO programme contributes to the national response and is aligned to the country’s aims of reducing both
    new infections and mortality substantially. As indicated in the National Strategic Framework for HIV and AIDS (NSF)
    2018−2022 this will be achieved by super-fast tracking the response in the next five years and will meet the following
    impact targets by 2022:1

          i.     Reduction of HIV incidence among adults by 90 per cent from a baseline of 2010;
          ii.    Reduction of incidence among 15−24 year-olds by 90 per cent from a baseline of 2010;
          iii.   Elimination of new HIV infections among infants to less than 0.05 per cent; and
          iv.    Reduction of AIDS deaths by 50 per cent.

    The programme is expected to contribute to regional and global targets, including those in the Eastern and Southern
    Africa (ESA) Ministerial Commitment, UNAIDS Fast-Track Strategy, the WHO End TB Strategy, the 2016 Political
    Declaration on HIV and AIDS and the Sustainable Development Goals:2

          i.     Achieve 90-90-90 targets for HIV and 90-(90)-90 targets for TB by 2020;
          ii.    Fewer than 200,000 new HIV infections and an 80 per cent reduction in TB incidence by 2030;
          iii.   Reduce early and unintended pregnancies among young people by 75 per cent by 2020;
          iv.    Expand community-led service delivery to cover at least 30 per cent of all service delivery by 2030; and
          v.     End HIV and TB as public health threats by 2030.

    1
         Government of Eswatini. 2018. National MultiSectoral HIV and AIDS Strategic Framework 2018−2022.
    2
         Eswatini TB-HIV Funding Request-Final

2
BACKGROUND AND CONTEXT
                                                                                                                        A

1.3         Methodology
The overall approach to data collection was a review of literature, key informant interviews and consultative meetings
as described below.

   i.     Literature review
A review of literature was undertaken focused on global and regional policy and strategy documents, national policies
and strategies, and development partners’ documents on technical, programmatic and funding support provided (see
Section 11 − list of documents reviewed).

   ii.    In-depth interviews
Twelve one-on-one in-depth interviews were carried out with staff from the Ministry of Health, the Ministry of Education,
UNESCO, the Department of Social Welfare, National Emergency Response Council on HIV and AIDS (NERCHA),
Central Statistical Office (CSO), implementing partners, UN funding partners, and the President’s Emergency Plan for
AIDS Relief (PEPFAR) through USAID (see annex 2). The UNICEF AGYW Stay Free tool was adapted and utilised for the
collection of information, some of which is included in this report.

Twenty one-on-one in-depth interviews were carried out with key informants in Mahlangatja, Mhlume and Somntongo.
These include the Tinkhundla Secretary, health service providers, teachers, community leaders, church leaders,
Rural Health Motivators, the police and Community-based Organizations (CBOs). The tool used was a key informant
interview guide customised to each key informant.

   iii.   Consultative meetings
An inception meeting was held with UNICEF, the Global Fund and CANGO to clarify the purpose and objectives of
the assignment and agree on a workplan for its execution. Consultative meetings continued throughout the process
of literature review, key informant interviews and the scoping for consensus-building and adding value to the final
deliverables. A stakeholder validation meeting is planned before finalisation of the Report.

   iv.    Focus Group Discussions
Twenty-two Focus Group Discussions (FGDs) were conducted with groups of adolescents and young people (in and
out-of-school) from the three Tinkhundla. Separate focus group discussions were convened with boys and girls, and
young women and young men as indicated in table 1 below. Two FGDs were also conducted with community members
(men and women). An FGD guide was used to structure the discussions. The respondents were purposively identified
in both rural and urban settings.

Table 1: Focus Group Discussions

 FOCUS GROUP DISCUSSION                   IN        OUT-OF-
                                        SCHOOL      SCHOOL
 Adolescent girls 10-14 years               3           -
 Adolescent girls 15-19 years               5           -
 Young women 20-24 years                    2           4
 Young men 20-24 years                      4           3
 Community members/Parents (2 FGDs)
                                                                                 WFGD with community members at Mgidzangcunu
                                                                                                 Community, Mhlume Inkhundla

                                                                                                                               3
i.     Check list
    As part of the scoping exercise, two standard checklists were developed and used for the collection of data in the
    Tinkhundla on (a) number of schools and (b) number of clinics/hospitals and the services they offer to adolescent girls
    and young women. One checklist completed for Mahlangatja clinic is attached in annex 2.

        ii.    Recruitment and training of data collectors
    Ten Data Collectors carried out fieldwork in Mahlangatja, Mhlume and Somntongo Tinkhundla. The Data Collectors
    were trained for two days (Tuesday 26 and Wednesday 27 September 2018) on the tools for data collection, how to
    administer them and on the respondents to be targeted. One of the ten Data Collectors was selected as Team Leader.
    The team of Data Collectors collected data from the three Tinkhundla, one after the other, for two days per Inkhundla,
    totalling six days of fieldwork.

        iii.   Method of data analysis
    The Data Collection team held daily de-briefing meetings to identify common themes from the information collected.
    The team transcribed the FGDs and the key informant interviews and used the output to develop an Inkhundla Report.
    The Data Collectors used a template to summarise Tinkhundla information under selected themes in line with the
    main report structure. Data triangulation was used in analysing both secondary and primary data culminating in the
    development of the Scoping Report.

        iv.    Ethical considerations for the scoping exercise
    CANGO fulfilled the requirements of the Research Ethics Committee (REC) by lodging the scoping exercise
    proposal before the committee for its determination. A waiver was granted to carry out the assignment.
    At field level, ethical issues of confidentiality and volunteering to participate in the scoping exercise were observed.
    Participants were briefed on the purpose of the scoping exercise and asked if they would volunteer to participate as
    either key informants, or focus group discussion participants and have photos captured during the process. They were
    assured that there would be no prejudice to those who opted out of the exercise. Those who volunteered to participate
    in the data collection were asked to sign a consent form.

    1.4         Limitations to the Scoping Exercise
    Three issues can be cited as limitations to the study:

    f AGYW data is not readily available as most data is not disaggregated by sex, for example the AGYW Dashboard
       managed by the Ministry of Health; and programme funding information does not provide specific funds for
       AGYW programming.
    f Qualitative data collection and analysis would have benefited from primary quantitative data to answer
       questions such as AGYW living arrangements and how many are out-of-school. Nevertheless, the report relied on
       secondary data where possible to fill the identified gaps. The information will further benefit from the Population
       and Housing Census Final Results 2017 when available.
    f Discussing sex and sex-related issues are not easy topics especially when talking to a stranger. Some of the
       adolescents and young people interviewed in the scoping exercise shied away from the discussion, especially
       those in the 10−14 year age group. However, the trained Data Collectors were able to involve everyone in the
       discussions.

4
BACKGROUND AND CONTEXT
                                                                                                                          A

2. Global and Subregional HIV Situation

According to UNAIDS 2018, 36.9 million people were living with HIV in 2017 globally (35.1 million adults; 18.2 million
women aged 15 years and above; and 1.8 million children aged below 15 years). The annual number of global deaths
from AIDS-related illness among people living with HIV (all ages) has declined from a peak of 1.9 million in 2004 to
940,000 in 2017. Since 2010, AIDS-related mortality has declined by 34 per cent. The global decline in deaths from AIDS-
related illness has largely been driven by progress in sub-Saharan Africa, particularly eastern and southern Africa,
which is home to 53 per cent of the world’s people living with HIV. AIDS-related mortality declined by 42 per cent from
2010 to 2017 in eastern and southern Africa, reflecting the rapid pace of treatment scale-up in the region.3

The UNAIDS Report further noted that mortality reductions remain higher among women than men. This gender gap
is particularly notable in sub-Saharan Africa, where 56 per cent of people living with HIV are women. Despite the
higher disease burden among women, more men living with HIV are dying. In 2017, an estimated 300,000 men in sub-
Saharan Africa died of AIDS-related illness compared to 270,000 women.4

The number of new HIV infections globally continued to decline in 2017. Modelled estimates show that new infections
(all ages) declined from a peak of 3.4 million in 1996 to 1.8 million in 2017. As is the case with AIDS-related mortality, the
reduction in new HIV infections between 2010 and 2017 was strongest in sub-Saharan Africa due to sharp reductions in
eastern and southern Africa (30 per cent decline). Despite the decline, progress is far slower than is required to reach
the 2020 milestone of less than 500,000 new infections. Women continue to account for a disproportionate percentage
of new HIV infections among adults (aged 15 and older) in sub-Saharan Africa: they represented 59 per cent of the
980,000 new adult HIV infections in 2017.5

AIDS-related illnesses remain the leading cause of death among women of reproductive age (15–49 years) globally,
and they are the second leading cause of death for young women aged 15–24 years in Africa. Many women are also
excluded from prevention of mother-to-child transmission of HIV (PMTCT) programmes due to distances to health
facilities, low quality of services, stigma and discrimination and lack of spousal/partner support, family or community
support. This leads to more than 1,000 infants being born with HIV every day in sub-Saharan Africa.6 In the Eastern and
Southern Africa Region, 93 per cent of the 940,000 pregnant women living with HIV received antiretroviral prophylaxis
in 2017,7 while 62 per cent of children born of HIV positive women received their virological test within the first two
months as compared to 23 per cent in 2009.8 Fifty-nine per cent of HIV positive children are receiving ART as of 2017.9
The region accounts for 90 per cent of new HIV infections in children in the world.10 Care and support to the children
made vulnerable by HIV and AIDS are nowhere near adequate. In most countries in the region, only around 20 per cent
or less of these children receive some sort of external support.11

3
     UNAIDS Data 2018.
4
     Ibid
5
     Ibid
6
     https://www.unicef.org/esaro/7310_Gender_and_PMTCT.html
7
     UNAIDS. 2018. Global AIDS Update ”Miles to Go”.
8
     UNICEF. 2018. Data – Infants HIV Testing 2017.
9
     UNAIDS. 2018. Fact Sheet – Latest statistics on status of the epidemic.
10
     UNICEF Eastern and Southern Africa (2015) Regional Analysis Report.
11
     https://www.unicef.org/esaro/5482_HIV_AIDS.html

                                                                                                                                 5
In Eastern and Southern Africa 2.7 million people aged 15−24 years live with HIV, which is more than half of all young
    people living with HIV globally.12 Although AIDS-related deaths in the ESAR among adolescents and young people
    have generally been decreasing, the mortality rate remains high among adolescent girls and young women and is
    increasing among adolescent boys and young men. In Eswatini and Lesotho, adolescent girls aged 15−17 years, have
    4 times higher HIV prevalence than their male peers.13 Adolescents are also underserved by HIV services and have
    lower adherence to medical appointments.14 Treatment adherence presents a significant challenge for adolescents
    living with HIV whether they acquired it vertically or horizontally.15 Child marriage is also a widespread problem in
    many countries in east and southern Africa, and is also a serious violation of girls’ human rights. It denies them their
    right to health care, to education, to live in security and to choose when and whom they marry. Child marriage has
    dire consequences especially for girls.16 Violence against children is also an issue of concern in Eastern and Southern
    Africa, with research carried out by UNICEF and partners revealing a picture of widespread violence against girls and
    boys. Of the gender-based violence cases recorded under the National Surveillance System (2016) in Eswatini, 35 per
    cent were of emotional abuse, 31 per cent were physical abuse and 19 per cent were sexual abuse cases.17 A study in
    Tanzania found that nearly 3 in 10 women and 1 in 7 men experienced sexual violence as children.18

    Studies carried out by UNICEF and Centers for Disease Control and Prevention in ESA showed that over 70 per cent
    of boys and girls reported severe beatings, with teachers and parents as primary perpetrators across most countries.
    Reporting of incidents of violence, however, is poor, with 50 per cent for girls and even fewer for boys. Of those who
    did report, less than half ever received services.19 A study on violence against children in Tanzania showed that 30 per
    cent of female respondents between the ages of 13 and 24 years who had lost one or both parents before reaching
    adulthood experienced sexual abuse as compared to 20 per cent of non-orphan respondents.20

    12
         https://www.unicef.org/esaro/5482_HIV_prevention.html
    13
         UNAIDS. 2015. UNAIDS Gap Report.
    14
         REPSSI. 2016. Resourcing Resilience; The Case of Social Protection for HIV Positive Children on ART in ESA.
    15
         RIATT-ESA. 2015. Intensify HIV Prevention and Treatment for Adolescents.
    16
         UNFPA ESARO website: http://esaro.unfpa.org/en/topics/child-marriage
    17
         Government of Eswatini. 2016. National Surveillance System on Violence in Eswatini. Annual Report for the year ended 2016.
    18
         https://www.unicef.org/esaro/5480_violence-against-children.html
    19
         UNICEF national population-based surveys in Eswatini, Kenya, Malawi, Tanzania and Zimbabwe.
    20
         Ibid.

6
BACKGROUND AND CONTEXT
                                                                                                                                           A

3. Global, Regional- and Country-Level
   Policy Environment

3.1             Commitments at Global Level
There are various commitments, conventions and strategies developed at global level aimed at ensuring the provision
of services for children, adolescents and young people. These are detailed in: the Convention on the Rights of the
Child; UNGASS Political Declaration on HIV and AIDS 2016; United Nations Sustainable Development Goals; UNAIDS
90-90-90 Strategy; Start Free, Stay Free, AIDS Free Framework; the WHO Global Health Strategies 2016−2021; and the
Global Strategy For Women’s, Children’s and Adolescents’ Health (2016−2030).

The Convention on the Rights of the Child (1989)21 is an internationally binding human rights treaty signed by all
UN member states (except the United States) which ensures the protection of children, adolescents and young
people. Some of the rights that the convention highlights are non-discrimination, protection of rights, survival and
development, ensuring the best interests of the child, access to health and health services, right to education, access
to information and mass media, and protection from all forms of violence.

Under the United Nations Sustainable Development Goals 2030,22 five goals speak specifically to children, adolescents
and young people in terms of universal health coverage; universal primary and secondary education; gender equality
and empowerment; productive employment and decent work; and access to justice as highlighted in the goals below:

            Goal 3: Ensure healthy lives and promote well-being for all at all ages;

            Goal 4: Ensure inclusive and equitable quality education and promote life-long learning opportunities for all;

            Goal 5: Achieve gender equality and empower all women and girls;

            Goal 8: Promote sustained, inclusive and sustainable economic growth, full and productive employment and decent
                    work for all; and

            Goal 16: Promote peaceful and inclusive societies for sustainable development, provide access to justice for all and
                     build effective, accountable and inclusive institutions at all levels.

The UNGASS Political Declaration on HIV and AIDS 201623 on the Fast Track to Accelerating the response to HIV and
to Ending the AIDS Epidemic by 2030 further recognizes the need for gender equality and equity; access to services;
and promotion of laws that fight against stigma and discrimination. These are detailed in the six points below adapted
from the Declaration:

      i.       Ensuring access to testing and treatment in the fight against HIV and AIDS;
      ii.      Pursuing transformative AIDS responses to contribute to gender equality and the empowerment of all
               women and girls;

21
     United Nations, 1989. Convention on the Rights of the Child Adopted and opened for signature, ratification and accession by General
     Assembly resolution 44/25 of 20 November 1989; entry into force 2 September 1990, in accordance with article 49.
22
     United Nations, 2015. Sustainable Development Goals, available at: https://sustainabledevelopment.un.org/?menu=1300
23
     UNGASS, 2016. Political Declaration on HIV and AIDS: On the Fast Track to Accelerating the Fight against HIV and to Ending the AIDS
     Epidemic by 2030.

                                                                                                                                               7
iii.      Ensuring access to high-quality HIV services, commodities and prevention while expanding coverage,
                    diversifying approaches and intensifying efforts to fight HIV and end the AIDS epidemic;
          iv.       Promoting laws, policies and practices to enable access to services and end HIV-related stigma and
                    discrimination;
          v.        Engaging and supporting people living with, at risk of and affected by HIV as well as other relevant
                    stakeholders in the AIDS response; and
          vi.       Leveraging regional leadership and institutions is essential to more effective AIDS responses.

    The UN 90-90-90 Strategy24 aims at countries achieving the three 90s and ensuring that no one is left behind where
    90 per cent of all people living with HIV know their HIV status; 90 per cent of all people with diagnosed HIV infection
    receive sustained antiretroviral therapy; and 90 per cent of all people receiving antiretroviral therapy have viral
    suppression by 2020.

    The Start Free, Stay Free, AIDS Free Framework,25 sponsored by UNAIDS, PEPFAR, World Health Organization (WHO),
    UNICEF and the Elizabeth Glaser Paediatric AIDS Foundation (EGPAF), built on the UNGASS Political Declaration
    and also the Global Plan for PMTCT and included critical targets related to children and adolescents living with HIV.
    Countries are to contribute to the achievement of the following global targets:

                 Start Free:
                     •    Eliminate new HIV infections among children (aged 0–14 years) by reducing the number of children newly
                          infected annually to less than 40,000 by 2018 and 20,000 by 2020.
                     •    Reach and sustain 95 per cent of pregnant women living with HIV with lifelong HIV treatment by 2018.
                 Stay Free:
                     •    Reduce the number of new HIV infections among adolescents and young women (aged 10–24 years) to less
                          than 100,000 by 2020.
                     •    Provide voluntary medical circumcision for HIV prevention to 25 million additional men by 2020, with a focus on
                          young men (aged 10–29 years).
                 AIDS Free:
                     •    Provide 1.6 million children (aged 0–14 years) and 1.2 million adolescents (aged 15–19 years) living with HIV
                          with antiretroviral therapy by 2018.
                     •    Provide 1.4 million children (aged 0–14 years) and 1 million adolescents (aged 15–19 years) with HIV treatment
                          by 2020.

    WHO Global Health Strategies 2016-202126 addresses three major public health issues: HIV, viral hepatitis (VH)
    and sexually transmitted infections (STI). The strategy states the need to prioritize combination HIV prevention to
    adolescents, girls and young women, and male sexual partners, particularly in high-burden settings in sub-Saharan
    Africa, using interventions that aim to reduce both vulnerability and risk behaviours, including gender-based and sexual
    violence and sexual risk behaviour associated with alcohol and other drug use. Secondly, it encourages the provision
    of guidance on combination HIV prevention, rapidly integrating new, evidence-based health sector interventions into
    HIV prevention packages for different epidemic contexts, with particular attention to female and male adolescents,
    girls, women and key populations (including young key populations).

    24
         UN. 2014. 90-90-90 targets
    25
         http://www.unaids.org/sites/default/files/media_asset/Stay_free_vision_mission_En.pdf
    26
         WHO. 2015. Global Health Sector Strategies on HIV, Viral Hepatitis and Sexually Transmitted Infections (STIs) 2016-2021. Briefing Note:
         October 2015.

8
BACKGROUND AND CONTEXT
                                                                                                                                       A

The Global Strategy For Women’s, Children’s and Adolescents’ Health (2016−2030)27 takes a life-course approach that
aims for the highest attainable standards of health and well-being − physical, mental and social − at every age,
cognisant that a person’s health at each stage of life affects health at other stages and also has cumulative effects for
the next generation. The Global Strategy focuses on survival, thriving and transformation:

              •    Survive: Ending preventable deaths

              •    Thrive: Ensuring health and well-being

              •    Transform: Expanding enabling environments.

3.2            Continental and Regional Policies and Strategies
Three policy documents at the African Union Commission (AU) level speak to the provision of comprehensive HIV
and AIDS services to adolescents and young women. These are the AU Agenda 2063, the AU Campaign to End Child
Marriages and the Catalytic Framework to End AIDS, TB and Eliminate Malaria. The AU Agenda 206328 highlights
child health and rights and provision of comprehensive services throughout the lifecycle as espoused in Aspiration
6: An Africa whose development is people-driven, relying on the potential of African people, especially its women
and youth, and caring for children. The AU Campaign to End Child Marriage in Africa: Call to Action 201329calls on
governments to end the harmful practice of child, early and forced marriage, while the Catalytic Framework to end
AIDS, TB and Eliminate Malaria in Africa (African Union, 2016)30, 31 highlights issues of social protection especially for
children, adolescents and young people; generation and use of evidence for policy and programme interventions;
evidence driven advocacy; and capacity building.

The revised Maputo Plan of Action 2016−203032 provides a framework to achieve universal access to comprehensive
sexual and reproductive health rights and services in the post-2015 period. It was developed by the African Union
Commission and follows on from the Maputo Plan of Action 2007-2015. The ultimate goal of the Plan of Action is to
guide the effective implementation of the continental policy framework on SRHR in order to end preventable maternal,
newborn, child and adolescent deaths, expand contraceptive use, reduce levels of unsafe abortion, end child marriage,
eradicate harmful traditional practices including female genital mutilation and prevent gender-based violence and
ensure access of adolescents and youth to SRH by 2030 in all countries in Africa.

27
     United Nations. 2015. The Global Strategy For Women’s, Children’s And Adolescents’ Health (2016-2030).
28
     African Union Commission. 2015. Agenda 2063: The Africa We Want.
29
     African Union Commission. 2013. Campaign To End Child Marriage In Africa: Call To Action 2013.
30
     African Union Commission. 2016. Catalytic Framework to End AIDS, TB and Eliminate Malaria In Africa By 2030. Working Group of the
     Specialised Technical Committee on Health, Population and Drug Control, Experts Meeting 25 to 26 April 2016, Addis Ababa; Ministers of
     Health Meeting Geneva, 21 May 2016.
31
     African Union Targets and Milestones to End AIDS, TB and Malaria by 2030.
32
     The African Union Commission. Maputo Plan Of Action 2016-2030 For The Operationalisation Of The Continental Policy Framework For
     Sexual And Reproductive Health And Rights.

                                                                                                                                              9
The Ministerial Commitment of the Eastern and Southern Africa (ESA) Meeting in 201333 ensures that all young people
     have access to high quality, comprehensive life skills-based HIV and sexuality education, and to appropriate youth-
     friendly health services. Below are some of the specific commitments:

     f Work together on a common agenda for all adolescents and young people to deliver comprehensive sexuality
          education (CSE) and youth-friendly SRH services that will strengthen our national responses to the HIV
          epidemic and reduce new HIV/STI infections, early and unintended pregnancy and strengthen care and support,
          particularly for those living with HIV.
     f Review − and where necessary amend − existing laws and policies on age of consent, child protection and
          teacher codes of conduct to improve independent access to sexual and reproductive health services for
          adolescents and young people and also protect children.
     f Make an AIDS-free future a reality by investing in effective, combination prevention strategies.
     f Ensure that the design and delivery of CSE and SRH programmes include ample participation by communities
          and families.
     f Integrate and scale up youth-friendly HIV and SRH services.
     f Ensure that health services are youth-friendly, non-judgemental, and confidential and reach adolescents and
          young people.
     f Strengthen gender equality and rights within education and health services.

     At the regional level of the Southern Africa Development Community (SADC), the SADC Health Protocol (1999)34
     addresses health needs for young people under Article 3 with one of its main objectives (g) to develop common
     strategies to address the health needs of women, children and other vulnerable groups. Article 17 alludes to the
     provision of appropriate childhood and adolescent health services essential for the critical foundation for growth and
     development of children, committing state parties to:

     f Co-operate in improving the health status of children and adolescents;
     f Develop and formulate coherent and standardised policies and set out targets with regard to child and
          adolescent health; and
     f Encourage adolescents to delay engaging in early sexual activity which may result in unwanted teenage
          pregnancies.

     The Maseru Declaration on the Fight against HIV/AIDS in the SADC region (2003)35 provides a framework for youths
     and children in a number of its provisions. The declaration placed emphasis on strengthening communities and
     families to prevent and mitigate the impact of HIV and AIDS on children and youth. In line with the Maseru Declaration,
     the goal of SADC interventions to combat the HIV and AIDS pandemic to decrease the number of individuals and
     families in the region infected and affected by HIV and AIDS so that they are no longer a threat to public health and to
     socioeconomic development as highlighted in the Regional Indicative Strategic Development Plan.36 The intervention
     areas include HIV prevention strategies that address emerging issues and special populations such as young women
     and girls and mobile populations; improving access to treatment for children and adolescents; improving quality of
     HIV treatment in terms of patient monitoring, adherence management, efficacy of commodities and enhancing and

     33
          UNAIDS. 2013. Ministerial Commitment on comprehensive sexuality education and sexual and reproductive health services for adoles-
          cents and young people in Eastern and Southern African (ESA). 6th - 7th December 2013 Held at the Westin, Cape town, South Africa.
     34
          SADC, 1999. SADC Protocol on Health.
     35
          SADC, 2003. Maseru Declaration on the Fight against HIV/AIDS in the SADC Region (2003).
     36
          SADC, 2015. Regional Indicative Strategic Development Plan 2015−2020; SADC Declaration on Youth Development and Empowerment.

10
BACKGROUND AND CONTEXT
                                                                                                                    A

sustaining treatment coverage; sustainable financing; domestication and monitoring of policies and frameworks; and
monitoring and evaluation of regional and global commitments.

The SADC Integrated HIV, SRH, TB and Malaria Strategy and Business Plan 2016−2037 is in place to ensure accelerated
effective delivery of quality and comprehensive health and related services for all people, irrespective of age, sexual
orientation, marital status and gender. The document specifically mentions that SADC should ensure that children,
adolescents, youth, people with disability and key populations for all programmes access HIV, SRH, TB and malaria
services. A dedicated section on adolescence and sexual health specifies the need for strategies to:

f Scale up access and quality of comprehensive sexuality education;
f Increase access to sexual and reproductive youth services; and
f Improve access to family planning services.

Other critical policy documents are the SADC 1998 Addendum on the Prevention and Eradication of Violence against
Women and Children; the Minimum Package for HIV and SRH Integration in the SADC Region (2015)38 and the Policy
Framework for Population Mobility and Communicable Diseases in the SADC Region (2009).39

3.3           Eswatini HIV and AIDS Policy Environment
Eswatini has developed some policies and strategies to guide the provision of comprehensive HIV and AIDS and health
services for children, adolescents and young people in the country. The vision for the country in the HIV response is
to end AIDS by 2022. Guided by the National MultiSectoral HIV and AIDS Strategic Framework (NSF) 2018−2022, the
country aims to reduce significantly both new infections and mortality through super-fast tracking the response in
the next five years. Key programmes to achieve this goal are: HIV primary prevention, treatment, care and support;
social protection and reduction of vulnerabilities, HIV response management, sustainable financing and strategic
information and research. The following impact targets are to be achieved by 2022:

f Reduction of HIV incidence among adults by 90 per cent from a baseline of 2010;
f Reduction of incidence among 15−24 years old by 90 per cent from a baseline of 2010;
f Elimination of new HIV infections among infants to less than 0.05 per cent; and
f Reduction of AIDS deaths by 50 per cent.

The NSF is complemented by new policies and strategies developed between 2016 and 2018 that include the roll-out of
the test-and-start programme (October 2016), differentiated care (“CommART”) (June 2016), routine viral load testing
(April 2017), shorter MDR-TB regimen (January 2017), the new national strategy to end violence (2017−2022), the new
MDR-TB guidelines, the country’s launch of the “Three Frees” Framework (May 2017), and the national frameworks on
HIV self-testing as well as pre-exposure prophylaxis (PrEP).

In July 2018, the Sexual Offences and Domestic Violence Bill received Royal Assent from His Majesty King Mswati III
to be enacted into law as the Sexual Offences and Domestic Violence Act, 2018. The goal of the Act is to promote the
protection of society’s most vulnerable, including women and children. The Act gives effect to certain rights enshrined
in the Constitution of Eswatini of 2005; strengthens and consolidates certain common law and statutory provisions so
as to adequately provide for dealing successfully with sexual offences and domestic violence and to provide adequate

37
     SADC, 2017. SADC Integrated HIV, SRH, TB and Malaria Strategy and Business Plan, 2016-20.
38
     SADC (2015) Minimum Package for HIV and SRH Integration in the SADC Region.
39
     SADC (2009) Policy Framework for Population Mobility and Communicable Diseases in the SADC Region.

                                                                                                                          11
protection to complainants; aims to end impunity of perpetrators by imposing terms of imprisonment on convicted
     persons that are proportionate to the crimes committed; and it gives effect to several international legal instruments
     that the country has ratified and accented to.

     The National Health Sector Strategic Plan II (2014−2018) was designed around the need to attain Universal Health
     Coverage with the health and related services. The SRH interventions under the strategy are aimed at the delay of
     sexual debut using a cultural-rooted approach; sharing of correct information for better understanding of HIV amongst
     adolescents and youth; strengthen capacity of service providers on tailored SRH and family health services at all
     levels; and promoting youth and adolescent comprehensive sexuality and family health services.40

     The goal of the revised National Education and Training Sector Policy (2018)41 is the provision of an equitable and
     inclusive education and training system that affords all learners access to free and compulsory basic education and
     senior secondary education of high quality, followed by the opportunity to continue with life-long education and
     training so enhancing their personal development and contributing to Eswatini’s cultural development, socioeconomic
     growth and global competiveness.

     The National Policy on Sexual and Reproductive Health of 2013 is a guide for the implementation of well-coordinated
     and integrated sexual and reproductive health and rights programmes for the attainment of the highest level of
     health and well-being for all people of Eswatini.42 The Framework notes that comprehensive sexuality education and
     information, and integrated SRH and HIV services shall be provided to children, adolescents and young people at all
     levels of the health care delivery systems and other relevant settings according to their age and need; and that the
     Ministry of Health shall provide an enabling environment and resources to provide adolescent sexual and reproductive
     health (ASRH) services and quality family planning information and care shall be provided to all women and men of
     reproductive age.43,44

     The overall goal of the National HIV Prevention Policy 201245 is to promote an enabling environment for the scaling
     up of biomedical and non-biomedical HIV prevention interventions to reduce the HIV incidence in Eswatini. The Policy
     states that SRH education shall be integrated into HIV and provided through life skills education programmes at
     all levels of formal and non-formal education settings as well as through community-based structures; for out-of-
     school youth, HIV prevention information, sexual and life skills education shall be made available through various
     interpersonal and mass media interventions that are tailor-made for the youth; all SRH services and commodities
     shall be made accessible to all individuals and provided in accordance with the national guiding protocols; dual
     protection against STIs, HIV and unintended pregnancy shall be emphasized; and SRH services shall be provided in
     line with the adolescent SRH policy and shall focus on the prevention of early pregnancies, STIs and HIV.46,47 The policy
     addresses structural and cultural factors that increase vulnerability to HIV infection to foster sustainable changes in
     both individual behaviours and social norms.

     The Children’s Protection and Welfare Act 201248 provides for the right of a child to access health care services from
     the age of 12 years, and the age of consent for HIV testing is 12 years as stipulated in the HIV prevention policy.

     40
          Ministry of Health, 2014. The Second National Health Sector Strategic Plan 2014−2018.
     41
          The Government of the Kingdom of Eswatini, 2018. National Education and Training Sector Policy.
     42
          Ministry of Health, 2013. National Policy on Sexual and Reproductive Health.
     43
          Ibid.
     44
          Eswatini’s TB/HIV Funding Request to the Global Fund: Matching Funds, 28 August 2017. Final.
     45
          Government of the Kingdom of Eswatini, 2012. National HIV Prevention Policy.
     46
          Ibid.
     47
          Eswatini’s TB/HIV Funding Request to the Global Fund: Matching Funds, 28 August 2017. Final.
     48
          Government of the Kingdom of Eswatini, 2012. Children’s Protection and Welfare Act 2012 (Act No. 6 of 2012).

12
BACKGROUND AND CONTEXT
                                                                                                                                     A

Further, the National Youth Policy 200949 calls for improved access to HIV/AIDS treatment for youth, the integration
of Life Skills Education (which includes sexuality education) curricula into all institutions, the promotion of school-
and community-based health clubs, and scale-up of SRH services targeting all youth, to reduce STI prevalence and
unplanned pregnancies.

The National Policy on HIV and AIDS 200150 noted the need to increase the capacity of women, youth and other
vulnerable or disadvantaged groups such as disabled persons, sex workers, children living on the streets, and others
to protect themselves against HIV and AIDS and other sexually transmitted infections.

Eswatini has policies in place that are aligned to regional, continental and global commitments that create a conducive
environment for the implementation of interventions for adolescents and young people, and specifically for AGYW as
shown above. However, implementation of some policies may be lagging behind due to a lack of practical guidelines
and implementation plans.

49
     Eswatini National Youth Policy, 2009.
50
     Zungu-Dirwayi, N. et.al., 2004. An Audit of HIV/AIDS Policies in Botswana, Eswatini, Lesotho, Mozambique, South Africa, and Zimbabwe.

                                                                                                                                             13
NATIONAL GEOGRAPHIC
     B.                                    AND PROGRAMMATIC
                                           SCOPING OF AGYW

     4. Statistical Snapshot

     Demography
     The Kingdom of Eswatini is a landlocked country in Southern Africa with an estimated land area of 17,364 km2. It
     shares its border with Mozambique to the East, the Republic of South Africa to the North, West and South. Eswatini
     is classified as a lower-middle income country. According to the Population and Housing Census 2017, the population
     of Eswatini is 1,093,238 comprised of 531,111 males (48.6 per cent) and 562,127 females (51.4 per cent). The sex ratio
     is 94 males per 100 females. The population can be described as young as the population pyramid indicates a high
     percentage of those aged 0−14 years making up 35.6per cent of the total. The population in the 15−64 year-old age
     group is 59.9 per cent while those in the age-group of 65 years and above is 4.5 per cent.51

     The total population of AGYW aged 15−24 years is 113,452 with adolescents aged 15−19 years totalling 59,213 and
     young women 20−24 years at 54,239. The total female population for the country is 562,127, meaning AGYW 15−24
     years account for 20.2 per cent of the female population. This figure increases to 31.5 per cent including girls aged
     10−14 years.52

     HIV epidemiology
     Data from the second Eswatini HIV Incidence Measurement Survey (SHIMS 2) (July 2017) indicates that prevalence of
     HIV among adults aged 15 years and older is 27 per cent (32.5% among females and 20.4% among males).53 It further
     states that since the first survey in 2011, new infections fell by nearly half, and viral load suppression among people
     living with HIV more than doubled. While the SHIMS 2 results reveal that achieving the 90-90-90 targets is a near
     reality in Eswatini, recent data from the 15th National HIV Semi-Annual Review (NaHSAR 15; data from July/December
     2016) and a 2015 key populations mapping exercise highlight the need for innovative approaches to find, test, treat
     and support the hardest-to-reach populations in order to reach 90 per cent coverage.54 HIV incidence also still remains
     persistently high among adolescent girls and young women.

     51
          Central Statistical Office, 2017. The 2017 Population and Housing Census Preliminary Results.
     52
          Ibid.
     53
          Government of the Kingdom of Eswatini, 2017. Eswatini HIV Incidence Measurement Survey 2: A Population-Based HIV Impact Assess-
          ment SHIMS2 2016–2017.
     54
          Eswatini TB-HIV Funding Note (Final) 20 August 2017.

14
NATIONAL GEOGRAPHIC AND PROGRAMMATIC SCOPING OF AGYW
                                                                                                                    B

Knowing one’s HIV status is the doorway to receiving treatment, care and support, yet most young people in Eswatini
do not know their status. According to the Population-Based HIV Impact Assessment 2017, only 66.1 per cent of HIV-
infected people aged 15−24 years know their HIV status, compared to 84.7 per cent in the adult population. Adolescent
girls (AG) and young women (YW) in Eswatini account for a larger proportion (71 per cent) of new HIV infections
among their age group compared to their male peers and HIV prevalence among females aged 20−24 years is more
than five times higher than that of their male counterparts.55 The Multiple Indicator Cluster Survey (MICS) 2014 Report
noted that three-quarters of AG aged 15−19 years are sexually active but only 40 per cent know their HIV status.56
Economic and social pressures fuel transactional and intergenerational sex, leaving AGYW even more at risk of HIV
infection. Below is a summary of indicators on AGYW.

Table 2: HIV, Knowledge and Sexual Behaviour Indicators for AGYW aged 15−24 years

     INDICATOR                                                                              TOTAL NUMBER/RATE
     Living with HIV (15−24 years)                                                                 23,195*
     • Male                                                                                        3,677*
     • Female                                                                                      19,518*

     New infections (15−24 years)                                                                   2,724*
     • Male                                                                                          475*
     • Female                                                                                       2,249*

     HIV prevalence (15−24 years)                                                                   9.7%*
     HIV incidence per 1000 (15−24 years)                                                           1.26*
     Per cent reduction in new HIV infections since 2010:                                       (UNAIDS 2017)
     • 15−19 years                                                                                  -40%
     • 20−24 years                                                                                  -29%
     • AGYW                                                                                         -35%

     Projected % increase in population size between 2016 and 2030                                  (UNDP)
     • 15−19 years                                                                                   16%
     • 20−24 years                                                                                    8%
                                                                                                     24%
     Percentage of women age 20−24 years who had at least one live birth before age 18        16.7% (MICS 2014)
     Adolescent birth rate per 1000 girls 15−19 years                                                 87
     Comprehensive knowledge/Knowledge about HIV prevention among young people (15−24)        49.1% (MICS 2014)
     Sexual debut before age 15                                                                3% (MICS 2014)
     Sex with partner 10 years or older                                                        15% (MICS 2014)
*Estimates as of April 2018

55
       Population-Based HIV Impact Assessment 2017
56
       CSO and UNICEF. 2016. Multiple Indicator Cluster Study 2014

                                                                                                                          15
5. Programme Results
     The government of Eswatini is implementing varied packages of services to address the HIV epidemic in the country
     detailed in the section below on intervention mapping. This section highlights programme results looking at indicators
     on social structural factors, intervention coverage for AGYW, and intervention coverage among male partners
     summarised in table 3.

     Table 3: Programme Results

                                     INDICATOR                                    RATE
      Social structural factors      Secondary school attendance
                                     Secondary school completion
                                     Use of mass media
                                     Married before age 15                        1.3% (MICS 2014)
                                     Married before age 18                        8.8% (MICS 2014)
                                     Intimate partner violence
      Intervention coverage          Condom use                                   (GoK of Eswatini 2017/18 SADC Report)
                                     Men 15−49 years                              26,022,145
                                                                                  (25,399,895 male condoms)
                                                                                  (622,250 Female condoms)
                                     HIV testing                                  Ministry of Health (2017)
                                     AGYW (15−24 years)                           160,578
                                     Men 15−49 years                              382,781
                                     Number of AGYW on ART                        11,491 (Ministry of Health 2017)
      Intervention coverage among    Number of men 15−49 circumcised              25% (MICS 2014),
      male partners
                                     Number of men 15 and above on ART            49,587 (2016); 54,922 (2017); 71,307* (2018)
                                     AGYW 15−20 years virally suppressed          8,744
     *Estimates as of April 2018

     6. Intervention Mapping
     In addressing the education, health and social welfare issues of adolescent girls and young women in Eswatini,
     the Government of the Kingdom works through the Ministry of Health, the Ministry of Education and Training, the
     Ministry of Sports, Culture and Youth and other relevant government departments and institutions. Development
     and implementing partners and stakeholders provide support to government to fulfil its goals and objectives. One
     of the priorities is reaching adolescent girls and young women with SRH, and HIV and AIDS services. The discussion
     below highlights some of the programmes currently being implemented, and in some cases those planned for these
     population sub-groups: adolescent girls 10−14; adolescent girls 15−19; young women 20−24 years; male sexual
     partners of AGYW 15−24 years and male sexual partners of AGYW 25−54 years.

     Young women’s access to standard package of SRH/HIV services (including condoms, HIV Test Services) ensured
     through specific actions, STI treatment and diagnoses)

     Eswatini is implementing the National Policy on Sexual and Reproductive Health of 2013. The ASRH curriculum is
     being rolled out in tertiary institutions, for example at the Southern Africa Nazarene University (SANU) where students

16
NATIONAL GEOGRAPHIC AND PROGRAMMATIC SCOPING OF AGYW
                                                                                                                                        B

are sensitised on SRH/HIV issues and services. The country has launched a new condom strategy. Condom promotion
and distribution is one of the key components in Eswatini’s combination prevention strategies to reduce the risk of
HIV exposure including the transmission of STIs and unintended pregnancies. The Kingdom of Eswatini has also put
in place a national condom committee, set up and constituted under the Ministry of Health’s leadership with support
from other key stakeholders in the country. In 2017 a total of 26,022,145 condoms were distributed in the country.
Female condoms constituted 2 per cent (622,250) of the distributed condoms and male condoms constituted 98 per
cent (25,399,895).57 Condoms are promoted and distributed through health facilities, cultural events and through
dispensers located in wash rooms. Condoms are not distributed in schools but information is disseminated through
Life Skills Education. Notwithstanding, the Child Protection and Welfare Act, 2012 provides for the right of a child to
access health care services from the age of 12 years.

PEPFAR is supporting the government in the provision of HIV Testing services (HTS). The DREAMS project, through its
mobile clinics and outreach services (‘DREAMS on Wheels’ mobiles), targets AGYW 15−24 years with comprehensive
SRH services, HTC, condoms and contraceptive method mix. Of the five Mobile Clinics, two focus on adolescent boys
and young men (ABYM) ‘Esangweni Services’ but AGYW are also provided with services. The mobile clinics service
communities on a daily basis. PEPFAR support is channelled to 24 Tinkhundla, and the Global Fund is funding another
19. The Young Heroes, under NERCHA, work at community level supporting young people living with HIV. They refer
cases to health facilities using the Ministry of Health (MOH) referral note.

In 2017, there were 477,559 tests performed with a 5.5 per cent HIV positivity rate. Of those tested 38.6 per cent were
adolescents and young people (see table 4).58

Table 4: Number of HIV Tests and Positivity for Adolescents and Young People 2017

                                                       NUMBER                                                        NUMBER
                                NUMBER                RECEIVED               NUMBER           NUMBER HIV            REFERRED    POSITIVITY
     AGE GROUP                   TESTED                RESULTS                TESTED            POSITIVE         FOR HIV CARE     RATE (%)
     10−14 years                    23,861                 23,853                12,545                   337             282        1.4%
     15−19 years                    61,660                 61,605                32,233                  1,490          1,326        2.4%
     20−24 years                    98,918                 98,809                50,709                  4,533          4,065        4.6%

The NGO Pact, in partnership with Elizabeth Glaser Paediatric AIDS Foundation (EGPAF) and John Hopkins Center for
Communication Programs (CCP), is implementing the Eswatini Ready, Resourceful and Risk Aware Project (Triple R)
(locally named the Insika ya Kusasa project).59 The goal of the five-year project is to prevent new HIV infections and
reduce vulnerability among orphans and vulnerable children (OVC), AG, and YW in Eswatini through the provision of
education support, psychosocial support, HIV prevention services, mentorships, family planning services, and STI
screening. Caregivers and parents receive economic strengthening support and parenting skills. The project helps
HIV-negative OVC, AG, and YW stay HIV-free and support those who are HIV-positive to lead healthy lives. There is
index testing in households of those OVC who test HIV positive. The project targets male and female OVC 0−17 years;
adolescent girls 15−19 years; young women 20−29 years; and biological and non-biological female caregivers of OVC.
Pact works at delivery level in Manzini, Lubombo, Hhohho and Shiselweni, with eleven implementing partners, four
of whom focus on GBV.

57
      Government of the Kingdom of Eswatini. 2018. Eswatini HIV and AIDS Annual Report to SADC 2017/18
58
      Ministry of Health, HIV 2017 Annual Programme Report.
59
      Eswatini Ready, Resourceful, Risk Aware (Triple R) (locally named Insika ya Kusasa), April 2018.

                                                                                                                                             17
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