Getting to Zero: Achievement of 95-95-95 and Declining Hiv Incidence in Eswatini

Background: Achieving UNAIDS global 95 targets among people living with HIV (PLHIV) is key to HIV epidemic control. Eswatini, a country with one of the severest HIV epidemics, has implemented an aggressive national HIV response with comprehensive HIV prevention and treatment services. We assessed progress towards these targets in the high HIV disease burden setting of Eswatini. Method(s): We compared 95-95-95 indicators and HIV incidence from two sequential Population-based HIV Impact Assessment (PHIA) surveys conducted in Eswatini in 2016 and 2021. These PHIAs were similarly designed as nationally representative household surveys among individuals 15 years and older. Respondents completed interviews and provided blood samples for HIV rapid testing (Determine and Unigold), antiretrovirals (ARV) testing, and viral load (VL) measurement. The first 95 (diagnosed PLHIV) was assessed by self-report or detectable ARVs;second 95 (on treatment) by self-report or detectable ARVs among diagnosed PLHIV, and third 95 (VL suppression, VLS) as VL < 1,000 copies/mL among PLHIV on treatment. Annual HIV incidence was estimated from recent infections (classified by HIV-1 LAg avidity assay, VL and ARV detection) using the formula recommended by the World Health Organization Incidence Working Group. Survey weights accounting for sample selection probabilities and adjusted for nonresponse and noncoverage were applied. Result(s): The 11,199 adults in the 2021 PHIA were at 94-97-96, while the 10,934 adults in the 2016 PHIA were at 87-89-91, a statistically significant increase of 5-10% in all 95 indicators (see Table). Target achievement varied by sex, but all 95 indicators improved among men (92-96-97 in 2021 vs 80-90-91 in 2016) and women (95-98-96 in 2021 vs 91-88-91 in 2016). Overall annual HIV incidence declined by 45% from 1.13% in 2016 to 0.62% in 2021 (p = 0.055). Annual HIV incidence in 2021 was nearly seven times higher among women (1.11%) than among men (0.17%). Conclusion(s): These findings reflect substantial progress toward HIV epidemic control, a remarkable achievement in the context of health, social and economic disruptions and challenges associated with the COVID-19 era. The 2021 data highlight remaining gaps in knowledge of HIV status, particularly among men, and HIV incidence reduction, particularly among women.

Strengthening primary care for diabetes and hypertension in Eswatini: study protocol for a nationwide cluster-randomized controlled trial.

BACKGROUND: Diabetes and hypertension are increasingly important population health challenges in Eswatini. Prior to this project, healthcare for these conditions was primarily provided through physician-led teams at tertiary care facilities and accessed by only a small fraction of people living with diabetes or hypertension. This trial tests and evaluates two community-based healthcare service models implemented at the national level, which involve health care personnel at primary care facilities and utilize the country's public sector community health worker cadre (the rural health motivators [RHMs]) to help generate demand for care. METHODS: This study is a cluster-randomized controlled trial with two treatment arms and one control arm. The unit of randomization is a primary healthcare facility along with all RHMs (and their corresponding service areas) assigned to the facility. A total of 84 primary healthcare facilities were randomized in a 1:1:1 ratio to the three study arms. The first treatment arm implements differentiated service delivery (DSD) models at the clinic and community levels with the objective of improving treatment uptake and adherence among clients with diabetes or hypertension. In the second treatment arm, community distribution points (CDPs), which previously targeted clients living with human immunodeficiency virus, extend their services to clients with diabetes or hypertension by allowing them to pick up medications and obtain routine nurse-led follow-up visits in their community rather than at the healthcare facility. In both treatment arms, RHMs visit households regularly, screen clients at risk, provide personalized counseling, and refer clients to either primary care clinics or the nearest CDP. In the control arm, primary care clinics provide diabetes and hypertension care services but without the involvement of RHMs and the implementation of DSD models or CDPs. The primary endpoints are mean glycated hemoglobin (HbA1c) and systolic blood pressure among adults aged 40 years and older living with diabetes or hypertension, respectively. These endpoints will be assessed through a household survey in the RHM service areas. In addition to the health impact evaluation, we will conduct studies on cost-effectiveness, syndemics, and the intervention's implementation processes. DISCUSSION: This study has the ambition to assist the Eswatini government in selecting the most effective delivery model for diabetes and hypertension care. The evidence generated with this national-level cluster-randomized controlled trial may also prove useful to policy makers in the wider Sub-Saharan African region. TRIAL REGISTRATION: NCT04183413. Trial registration date: December 3, 2019.

Understanding the 2021 eSwatini school protests: theoretical reflections of an educator

During September and October 2021, eSwatini experienced school demonstrations unprecedented in the country's history. Drawing on a socio-emotional development framework and frustration-aggression theory, the article presents an educator's theoretically informed reflections on these events. It explores the possibility that the demonstrations are not simply a reflection of the prevalent political riots presently sweeping the country. Rather, they further expose the fundamental deficiencies in the country's political and education system. Utilising personal observations, contemporary news reports and an extensive literature review, the article explores the possibility that the violence seen in schools can be both a communicative strategy and an expression of negative emotions arising from both direct and indirect educational consequences of the pandemic, and further driven by the prevailing political system and the government's failure to meet students' needs. Building on this, the article suggests strategies that educators and policymakers could employ to address students' socio-emotional needs, thereby averting future emotional eruptions and violent behaviours. © 2023 The Institute of Social and Economic Research.

The Silent Pandemic: the Impact of COVID-19 on the Mental Health of Adolescents Living with HIV.

Purpose of Review: The pandemic caused by the coronavirus disease (COVID-19) has resulted in millions of confirmed cases and likely more than six million deaths globally Worldometer (2022). We sought to understand secondary mental effects in adolescents living with HIV (ALHIV) on the African continent caused by lockdowns, school closures, and other restriction measures for infection control. We reviewed the broader literature and conducted 86 retrospective chart reviews of mental health disorders of ALHIV and interventions utilized at a pediatric clinic in Eswatini. Recent Findings: ALHIVs are disproportionately affected by mental health disorders. The COVID-19 pandemic has exacerbated adverse mental health outcomes of adolescents on the African continent, especially for ALHIV. There have been many calls for researchers, clinicians, and governments to prioritize mental health in adolescents going forward. Summary: In pediatric clinics in Eswatini, Malawi, and Uganda, there were psychosocial measures in place prior to the COVID-19 pandemic for ALHIV. After looking closely at a pediatric clinic in Eswatini, we found that many interventions were paused and new psychosocial interventions compatible with social distancing were instead utilized by clinicians. Even so, after multidisciplinary management comprising of interventions such as psychotherapy, pharmacotherapy, referral to psychologists/psychiatrists, and enrollment in peer support groups, the PHQ-9 depressions scores of ALHIV during the COVID-19 significantly improved. We found that there is a need for age-specific standardized tools to measure depression in ALHIV. Furthermore, more research is needed on the effectiveness and scope of psychosocial interventions for ALHIV post-COVID-19 throughout Eswatini and the African continent.

The Impact of the COVID-19 Pandemic on Tuberculosis Case Notification and Treatment Outcomes in Eswatini.

Objectives: We investigated the impact of COVID-19 on tuberculosis (TB) case notification and treatment outcomes in Eswatini. Methods: A comparative retrospective cohort study was conducted using TB data from eight facilities. An interrupted time series analysis, using segmented Poisson regression was done to assess the impact of COVID-19 on TB case notification comparing period before (December 2018-February 2020, n = 1,560) and during the pandemic (March 2020-May 2021, n = 840). Case notification was defined as number of TB cases registered in the TB treatment register. Treatment outcomes was result assigned to patients at the end of treatment according to WHO rules. Results: There was a significant decrease in TB case notification (IRR 0.71, 95% CI: 0.60-0.83) and a significant increase in death rate among registrants during the pandemic (21.3%) compared to pre-pandemic (10.8%, p < 0.01). Logistic regression indicated higher odds of unfavorable outcomes (death, lost-to-follow-up, and not evaluated) during the pandemic than pre-pandemic (aOR 2.91, 95% CI: 2.17-3.89). Conclusion: COVID-19 negatively impacted TB services in Eswatini. Eswatini should invest in strategies to safe-guard the health system against similar pandemics.

The role of emergency medical teams in Eswatini during the COVID-19 pandemic.

The paper documents experiences and lesson learned in responding to COVID-19 pandemic in Eswatini with the support of the Emergency Medical Teams. WHO databases, operation reports and hospitalization records were reviewed. The WHO Emergency Medical Teams built the capacity of the local response teams in Eswatini. The conclusion is that following the intervention of the WHO Emergency Medical Teams, Eswatini is better prepared to respond to the ongoing COVID-19 pandemic and future outbreaks.

Supporting communities of practice - A Journey to effective problem-solving [version 1, peer review: 2 approved with reservations, 1 not approved]

In contexts of scarce resources, varied assets, and diverse communities, engaging local stakeholders in the problem-solving process is critical to develop interventions for HIV prevention and treatment. Communities of practice (CPs) - groups of people organized around a key purpose and a delivery point - can develop expertise in identifying their local community's key challenges and selecting viable solutions. We propose a framework for systematically understanding the stages a CP may go through as it develops its capacity to identify and solve problems and implement good practices. Our framework is based on the experience of practitioners of the LISTEN model (Local Initiatives Scaled Through Enterprise Networks) in eight local-level CPs in Kenya and Eswatini. LISTEN seeks to help CPs integrate continuous improvement processes, data, and human-centered design into their development and solutioning activities. The four stages in our framework for a CP's problem-solving journey are: 1) Community Identity: Identify and understand the community's purpose and goals, and build rapport with its members and leaders;2) Quick Win: Use a process of human-centered design to obtain a rapid and clear success in addressing a problem that the local community has identified for itself and which it can tackle with its own resources;3) Stewardship: Support the CP in addressing more complex or long-term issues, including links to other CPs at the localcommunity or higher levels to disseminate knowledge and obtain resources and support, where needed;and 4) Evolution: Support the CP as it transitions into potentially new structures or functions. For each stage of the framework, we describe the kinds of support that may be provided to the CP in the LISTEN model, and the types of tools that could be developed to assist them in problem-solving and in disseminating sustainable solutions. Copyright © 2020. Hanschke C et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Africa ‘not on track to reach 2030 HIV/AIDS targets’

Speed read Researchers estimated the likelihood of 38 African countries reaching 2030 HIV/AIDS targets The chances of reaching HIV testing or condom use targets are less than 30 per cent As COVID-19 takes centre stage, Africa cannot afford to not fight HIV/AIDS, says an expert [NAIROBI] The likelihood of African countries reaching HIV testing and condom use targets by 2030 is only 12.1 per cent and 28.5 per cent respectively, making the need for more testing and treatment a priority, a modelling study suggests. The Joint United Nations Programme on HIV/AIDS (UNAIDS) launched ambitious targets in 2014 to end the AIDS epidemic by 2030 by achieving 95 per cent diagnosis and 95 per cent of people with HIV taking medications against the disease. Stuart Gilmour, St. Luke’s International University In 2019, there were 690,000 AIDS-related deaths and 1.7 million new infections, with young women and adolescent girls accounting for about 25 per cent of new infections in Sub-Saharan Africa despite making up about ten per cent of the population, according to UNAIDS.

Predicting COVID-19 Infections in Eswatini Using the Maximum Likelihood Estimation Method.

COVID-19 country spikes have been reported at varying temporal scales as a result of differences in the disease-driving factors. Factors affecting case load and mortality rates have varied between countries and regions. We investigated the association between socio-economic, weather, demographic and health variables with the reported cases of COVID-19 in Eswatini using the maximum likelihood estimation method for count data. A generalized Poisson regression (GPR) model was fitted with the data comprising 15 covariates to predict COVID-19 risk in the whole of Eswatini. The results show that the variables that were key determinants in the spread of the disease were those that included the proportion of elderly above 55 years at 98% (95% CI: 97-99%) and the proportion of youth below the age of 35 years at 8% (95% CI: 1.7-38%) with a pseudo R-square of 0.72. However, in the early phase of the virus when cases were fewer, results from the Poisson regression showed that household size, household density and poverty index were associated with reported COVID-19 cases in the country. We then produced a disease-risk map of predicted COVID-19 in Eswatini using variables that were selected by the regression model at a 5% significance level. The map could be used by the country to plan and prioritize health interventions against COVID-19. The identified areas of high risk may be further investigated to find out the risk amplifiers and assess what could be done to prevent them.

The Dynamics of Language: A Linguistic Analysis of the Framing of COVID-19 in Eswatini

COVID-19 has drastically disrupted the lives of many people globally, and the havoc it has wreaked has shattered world economies. The effects of COVID-19 in Eswatini (formerly Swaziland) are threatening the very foundations of the country. Referenced in the national language, its effects manifest in the perceptions and experiences shared among Swazis (emaSwati) about the scourge. This article investigates the pandemic's impact on Swati (siSwati) and the ways in which Swazis adapted their language-related tropes in the face of unprecedented social and economic disruptions. Data are drawn from government briefings, news bulletins, media interviews and addresses. The findings demonstrate that COVID-19 has produced neologisms and expressions that index Swazis cultural views. While a morpho-syntactic analysis of the neologisms demonstrates that they derive from varied word-building mechanisms and exhibit COVID-19's distinctive characteristics of transmissibility, pathology, and annihilation, the measures to contain COVID-19 are presented aesthetically to dispel the anxiety associated with the pandemic.

Towards an efficient post Covid-19 ICT based extension service delivery model for the sugar industry of eSwatini

This study presents a designed ICT based extension service delivery system for the sugar industry of Eswatini. The model is an improvement of the current system and it presents a delivery system that is void of many limitations. This model emanates from findings of a survey which involved all smallholder sugarcane farmers (N=172) and their extension officers (N=17). The survey investigated how information and knowledge are currently managed within the sugar industry. Basically, the model revolves around the use of mobile phones to relay information among the sugar industry stakeholders in a timely, more organised, productive and cost-effective ways, without contravention of the COVID-19 pandemic protocols. Sugarcane stakeholders can now be able to exchange information using the model without having to meet physically, which is what most of the traditional approaches required. The exchange of information can be in a form of voiced, pre-recorded information in the form of texts, audio, or audio visuals. This would go a long way in enhancing smallholder farmer's productivity as it has the potential of empowering more rural sugarcane farmers with crucial information for improved productivity. The model has the potential to sustain itself as the participation of the stakeholders is promoted.

Factors Associated with Healthy Life Expectancy: An Ecological Analysis of Global Data

Healthy life expectancy (HALE) measures the quality of life a person expects to live. This study aims to find out the most associated factors of HALE at birth globally. The data of 212 countries came from the World Health Organization, Worldometer, World Bank, and United Nations. HALE at birth is considered as the dependent variable;and social, economic, and health factors are considered as the predictors. Descriptive statistics, Pearson’s correlation analysis, and multiple linear regression models were used as the statistical tools to reach the objective. The results revealed that HALE is found lower in Central African Republic and higher in Singapore. The highest death rate due to coronavirus disease 2019 (COVID 19), alcohol consumption rate, human immunodeficiency virus (HIV) prevalence rate, and average household size are found in Nicaragua, Moldova Republic, Eswatini, and Senegal, respectively. And the lowest recovery rate from COVID 19, and universal health coverage (UHC) service index are found in Tajikistan, and Montserrat, respectively. The recovery rate from COVID 19, UHC service index, gross domestic product (GDP), current health expenditure, tuberculosis (TB) incidence, tobacco smoking, HIV prevalence rate and average household size were significantly correlated with the HALE at birth. The multiple linear regression models identified that the UHC service index, alcohol consumption rate, HIV prevalence rate and average household size are the most associate factors of HALE at birth globally. Therefore, the necessary steps should be taken to maximize the UHC service index, and to minimize the alcohol consumption rate, HIV prevalence rate and average household size for increasing the HALE at birth in the world.

Risk Factors Associated with COVID-19 Infections among Healthcare Workers in Eswatini: A Cross-Sectional Study

Background: The coronavirus disease 2019 (COVID-19) pandemic has spread with alarming speed, infecting millions globally, including Eswatini. Despite the institutionalization of measures by the Ministry of Health (MoH) to fight the pandemic, the cumulative number of people infected with COVID-19 has kept increasing daily. We sought to assess risk factors for COVID-19 infections among Health care workers (HCWs) in selected health facilities of the Lubombo region of Eswatini. Methods: A cross-sectional design and systematic stratified sampling were used to select the participants. Results: The study enrolled 333 HCWs, with the majority (201, 60.4%) being females, and the participants’ mean age was 33 years. The study showed that not having an isolation arrangement in a health facility for people suspected to have COVID-19 presents risk to HCWs for COVID-19 (Crude Odds Ratio (COR) = 2.5, 95%CI: 1.0–6.2), p = 0.50;Adjusted Odds Ratio (AOR) = 3.0, 95% confidence interval (CI) 1.0–8.7, p = 0.038). Likewise, HCWs who rarely followed infection prevention and control (IPC) measures were at higher risk of COVID-19 infection than those who followed such measures (COR = 4.2, 95%CI: 1.1–17.2, p = 0.041;AOR = 6.5, 95%CI: 1.4–30.0, p = 0.016), and HCWs exposed to a colleague diagnosed with COVID-19 were at higher risk of being infected themselves (AOR = 11.4;95%CI: 0.9–135.7;p = 0.054). Conclusion: An active COVID-19 symptoms screening, triage and isolation arrangement for suspected COVID-19 clients for all clients entering the facility increases protection of HCWs from COVID-19. Reinforcement of all infection prevention and control measures to prevent exposures from infected patients and colleagues is essential.

ASSESSMENT OF THE PERCEIVED USEFULNESS OF MOBILE PHONE TECHNOLOGY FOR COMMUNICATION IN LEARNING BY DISTANCE EDUCATION STUDENTS IN A RURAL-BASED UNIVERSITY

The study sought to establish distance education students' perceived usefulness of mobile phone technology for communication in learning. Furthermore, the study hypothesised an association between the respondents' biographical details and their perceived usefulness of mobile phone technology for communication in learning. The study was located within the positivist research paradigm, followed a quantitative research approach, and utilised a descriptive research strategy. The Technology Acceptance Model by Davis (1989) and the Community of Inquiry framework by Garrison (2009) informed the study. A stratified random sample of 337 distance education students responded to an online-administered structured questionnaire. Important ethical issues such as informed content, anonymity and confidentiality, as well as ethical clearance and informed consent were considered. Data were analysed statistically, with the aid of the SPSS version 25 software. Statistical data were presented in form of percentages and means. The chisquare test was utilised to respond to the hypotheses. The study found that the respondents affirmed that mobile phone technology was useful for communication in learning, as it allowed students to use text messages, calls, WhatsApp instant messages, emails, and notifications to enhance learning experiences. The study concludes that mobile phone technology has become an integral component of the learning process in distance education. Students were aware of the usefulness of mobile technology for learning, and were prepared to use the technology for flexible, anytime and anywhere learning. The study also found that there was no significant relationship between age, gender, programme and level of study;and the perceived usefulness of mobile phone technology for communication in learning. Given the findings, recommendations are made to formalise the integration of mobile phone technology in distance learning, by making smartphones and internet connectivity available for course instructors and tutors. Furthermore, course instructors and students should be developed and supported to derive maximum benefits from mobile phone utilisation for learning.

COVID-19: Understanding and Responding to the Educational Implications for the Vulnerable Children of Eswatini

In a bid to contain the spread and infection rate of COVID-19, Eswatini closed all its schools on 17 March 2020, and for a year they remained closed. Despite education being the only viable means towards a better future, the closing of schools set-off to heighten prevailing educational disparities towards academic access, experience and achievement for the vulnerable children of the country. Adopting intersectionality as a theoretical framework, the paper seeks to analyse the educational effects of COVID-19 on the vulnerable children of Eswatini. The aim is to identify and discuss how educational systems and processes amidst the COVID-19 era sought to amplify the already compounded, complex and dominant educational disparities for children affected by vulnerability. A systematic literature review was conducted to understand child poverty and vulnerability in Eswatini schools and the implications of the COVID-19 school restrictions on the vulnerable children. Strategies to minimise the adverse effects of the pandemic on inclusive and equitable schooling for the vulnerable children have been suggested.

Re-Envisioning and Restructuring Blended Learning for Underprivileged Communities

Challenges in the educational arena are not new phenomena. However, with the recent outbreak of the COVID-19 pandemic, researchers and educators have been made even more aware of the need for a paradigm shift in education. Blended learning, as opposed to fully online learning or traditional face-to-face teaching, has been well-researched and has been found to have the potential to provide better educational solutions in challenging contexts. These contexts range from pandemic situations where social distancing is the order of the day to financial and time constraints regarding full-time study, as well as limited physical capacity at institutions. Blended learning solutions are often designed for resourceful institutions and cannot be easily implemented in developing countries and in communities where resources are limited. Typical issues like connectivity, accessibility, lack of suitable devices, and affordability need to be taken into consideration and in cognizance of blended learning interventions. These challenges are often neglected in blended learning research but are critical discussions to be had. "Re-Envisioning and Restructuring Blended Learning for Underprivileged Communities" shares how institutions in the developing world and less privileged communities have re-imagined and restructured blended education to enhance teaching and learning for underprivileged communities. This book aims to address blended learning solutions across institutional, program, course, and activity levels. The chapters will cover a variety of learning environments, from rural settings to less developed countries and more, and explore the programs and courses designed to improve student success and accessibility in diverse student populations. This book is ideally intended for teachers, administrators, teacher educators, practitioners, stakeholders, researchers, academicians, and students who are interested in blended learning opportunities in less-privileged settings and to underserved and marginalized populations.

Forecasting Daily New Covid-19 Cases in the Kingdom Of Eswatini Using Artificial Neural Networks

In this research article, the ANN approach was applied to analyze daily new COVID-19 cases in the Kingdom of Eswatini. The employed data covers the period 1 January 2020 to 31 December 2020 and the out-of-sample period ranges over the period 1 January 2021 to 31 May 2021. The residuals and forecast evaluation criteria (Error, MSE and MAE) of the applied model indicate that the model is stable in forecasting daily COVID-19 cases in Eswatini. The results of the study indicate that daily COVID cases will generally be between 0-260 cases over the out of sample period. Therefore the health authorities in Eswatini should continue enforcing the implementation of WHO guidelines on prevention and control of COVID-19.

Spatial risk assessment of an emerging pandemic under data scarcity: A case of COVID-19 in Eswatini.

Coronavirus (COVID-19) has rapidly spread across many countries in pandemic proportions since the first case was reported in Hubei, China in December 2019. Understanding transmission, susceptibility and exposure risks is crucial for surveillance, control and response to the disease. Knowing the geographic distribution of health resource scarcity areas is necessary if a country is to adequately anticipate and prepare for the full impact of infections. We explored the potential to undertake a spatial risk assessment of an emerging pandemic under data scarcity in Eswatini. We used a set of socio-economic and demographic variables to identify epidemic risk prone areas in the country. Three risk zone levels for COVID-19 were identified in the country. The analysis showed that about 29% (320 818) of the population were located in the high risk zone and these were people who could potentially be infected with COVID-19 in the absence of mitigation measures. A majority of cases and deaths attributed to COVID-19 would likely remain unknown but our estimate could be used to gauge the full burden of the disease. Approximating and quantifying the number of people who may be potentially infected with COVID-19 remains impossible under data scarcity and limited healthcare capacity especially in sub-Saharan Africa. We provided an estimation method that could support the pandemic risk forecasting, preparedness and response measures in the midst of data scarcity. The resultant map products could be used to guide on-the-ground surveillance and response efforts.

Governance of Eswatini Apparel Regional Value Chains and the Implications of Covid-19.

There is a growing literature on the impact of Covid-19 on commercial and labour conditions at suppliers in apparel global value chains (GVCs). Yet much less is known about the implications for suppliers operating in regional value chains (RVCs) in the global South. In this article, we focus on Eswatini, which has grown to become the largest African manufacturer and exporter of apparel to the region. We draw on a combination of firm-level export data and interviews with stakeholders before and after the Covid-19 lockdown to shed light on the influence of private and public governance on suppliers' economic and social upgrading and downgrading. We point to the coexistence of two separate private governance structures: the first characterised by direct contracts between South African retailers and large manufacturers (direct suppliers); the second operating through indirect purchasing via intermediaries from relatively smaller producers (indirect suppliers). While direct suppliers enjoyed higher levels of economic and social upgrading than indirect suppliers before Covid-19, the pandemic reinforced this division, with severe price cuts for indirect suppliers. Furthermore, while retailers provided some direct suppliers with support throughout the crisis, this was not the case for indirect suppliers, who remain comparatively more vulnerable. In terms of public governance, the negative consequences of the lockdown on firms' income and workers' livelihoods have been compounded by the state's ineffective response. Our paper contributes to the research on RVCs in the global South, enhancing our understanding of how different governance structures and external shocks affect firms' and workers' upgrading and downgrading prospects.

La publications à propos l'impact de la COVID-19 sur les conditions commerciales et du travail chez les fournisseurs des chaines de valeur globales (en anglais : Global Value Chains, GVCs), dans le secteur de l'habillement, est en croissance. Cependant, on connait beaucoup moins à propos les implications de la COVID-19 sur les fournisseurs qui opèrent au niveau des chaines de valeur régionales (en anglais : Regional Value Chains, RVCs) dans les pays du Sud. Dans cet article, nous nous concentrons sur Eswatini, qui est devenu le plus grand producteur Africain et exportateur d'habillement dans la région. Combinant des données collectés au niveau de l'entreprise sur ses exportations, et des entretiens avec plusieurs partis prenants avant et après le confinement COVID-19, nous illustrons l'influence de la gouvernance publique et privée sur la revalorisation et dévalorisation sociale et économique des fournisseurs. Nous attirons l'attention à la coexistence de deux structures séparés de gouvernance privée : la première structure est caractérisée par des contrats directs entre les détaillants de l'Afrique du Sud, et les gros producteurs (fournisseurs directs) ; la deuxième structure est assurée par les achats indirects chez les producteurs relativement plus petits (fournisseurs indirects) par des intermédiaires. Alors que les fournisseurs directs bénéficiaient de des niveaux de revalorisation économique et sociale plus élevés même avant la COVID-19, la pandémie a renforcé leur séparation par rapport aux fournisseurs indirects ; ces-ci ont plutôt subi une forte réduction des prix payés pour leur production. D'ailleurs, les détaillants ont soutenu les fournisseurs directs pendant la crise, mais ceci n'a pas été le cas pour les fournisseurs indirects, qui demeurent plus vulnérables. En ce qui concerne la gouvernance publique, les conséquences négatives du confinement sur le revenu des entreprises et sur la subsistance des travailleurs ont été aggravés par les interventions inefficaces de l'état. Cet étude contribue à la recherche sur les RVCs dans les pays du Sud, améliorant notre compréhension de comment les différentes structures de gouvernance et les chocs externes touchent les perspectives de valorisation et dévalorisation des entreprises et des travailleurs.

Universal test and treat in relation to HIV disease progression: results from a stepped-wedge trial in Eswatini.

OBJECTIVES: Universal test and treat (UTT) is recommended for people living with HIV (PLHIV) to reduce morbidity/mortality and minimize transmission. However, concerns exist that this strategy may lead to more crowded hospitals, longer wait times and poorer service, adversely impacting health outcomes for clients with severe disease. We assessed how UTT was related to markers of disease progression in PLHIV overall and specifically among clients with low CD4 count/high World Health Organization (WHO) stage. METHODS: The analysis was conducted using data from a stepped-wedge trial of UTT in 14 government-managed health facilities in Eswatini from 2014 to 2017. Disease progression was defined as CD4 count falling below 200 cells/µL or baseline value, > 10% weight loss, body mass index (BMI) dropping below 18.5, incident tuberculosis (TB) or HIV-related death; these outcomes also were assessed individually. We assessed multivariate Cox proportional hazard models overall and specifically among clients with CD4 count < 350 cells/µL or WHO stage 3-4 at enrolment. RESULTS: Eight hundred and seven of 3176 clients demonstrated at least one marker of disease progression over 2339 person-years of follow-up. Overall, 62.4% of clients were female; 57.2% were < 35 years old. Compared to clients not exposed to UTT, those exposed to UTT had a lower rate of disease progression overall [adjusted hazard ratio (aHR) 0.60; 95% confidence interval (CI) 0.46-0.78] and a lower rate of CD4 decline (aHR 0.40; 95% CI 0.27-0.58). When the analysis was limited to clients with CD4 count < 350 cells/µL or WHO stage 3-4, UTT was not associated with disease progression (aHR 0.92; 95% CI 0.66-1.29). CONCLUSIONS: UTT reduced HIV disease progression overall and was not detrimental for clients with more severe disease.