When Dr. Caroline Ryan became the CDC Country Director for Eswatini in 2015, the small kingdom in Southern Africa (then known as Swaziland) had the highest rate of HIV in the world – 27% of the adult population. But there was reason to be optimistic.

The following year, a study showed that the number of new infections in the country had been nearly halved and the number of people who were on antiretrovirals that were virally suppressed had doubled.

“It gave us all an idea that even without an HIV vaccine, the impact of an HIV program scale-up could have a significant impact on the HIV epidemic,” said Ryan during a recent phone interview.

Four years later, Eswatini became only the second nation in the world, along with Switzerland, to achieve 95-95-95, UNAIDS’s ambitious global HIV treatment target (95% of people living with HIV diagnosed, 95% of those diagnosed on antiretroviral therapy, and 95% of those treated virally suppressed).

“HIV devastated a whole generation of people, including the political and economic infrastructures. So, the fact that Eswatini was able to achieve 95-95-95, people were really quite stunned,” said Ryan, who has spent her career researching and combating infectious diseases around the world.

Ryan is a former infectious disease fellow and assistant professor of medicine at the University of Washington School of Medicine. She also earned her master’s degree in public health while doing HIV research overseas with the University of Washington Center for AIDS & STD. She later spent a decade working for the Office of the U.S. Global AIDS Coordinator in Washington, D.C, where she helped develop the President's Emergency Plan for AIDS Relief (PEPFAR).

As the current leader of the CDC’s HIV & TB division in Eswatini, Ryan has played an active role in the country’s ongoing fight against the HIV epidemic. A fight which has been further complicated by the COVID-19 pandemic. 

“I had colleagues that said to me, ‘I lived through HIV and I thought it was the worst thing that could ever happen, but this is worse,’” said Ryan.

On July 1, Ryan will take on a new assignment as the CDC Country Director for Ethiopia. She spoke further about achieving 95-95-95, adapting to new public health emergencies, and the lessons she will carry forward into her new role. These are edited excerpts from that conversation.

It sounds like the approach to achieving 95-95-95 in Eswatini was multi-pronged.

We looked first at stopping transmission through programs promoting PrEP, treating sexually transmitted diseases, and providing voluntary medical male circumcision. For those on antiretrovirals (ARVs), we also supported communities and facilities, trying to make sure we could get people to come in and get their medicines. When they couldn't go to facilities, we did community-based distribution and made sure we had very good follow-up. And we did that by embedding multi-disciplinary teams that worked alongside the Ministry of Health at both the national and the regional level.

Do you feel this approach is repeatable in other countries, or is there something special about Eswatini that made this possible there?

I think it's very repeatable. Our model is the PEPFAR model. And the thing that makes the PEPFAR model work is that it's a data-driven process. We have very discreet indicators that we monitor on an ongoing basis so that we can do real-time programmatic changes to improve the program outcomes.

In Eswatini it was especially important to have a strong relationship with the government in multiple sectors, in addition to the Ministry of Health. Political will with the institutional stakeholders was very important. I think when your funding levels are sufficient for the program you want to implement, that also was very, very helpful.

The understanding of the gravitas of the epidemic, a very competent government partnership, sufficient resources, and then the ability to be monitoring ongoing and using data to improve performance. Those were the successful elements.

What were some of the main obstacles to achieving 95-95-95 and how did you overcome them?

When I first came to Eswatini, one of the biggest problems we had was we would diagnose a lot of people, but less than 30% of them would ever get linked to care. So, we started this program called CommLink, and we hired people that were HIV patients on antiretroviral therapy and virally suppressed. We call them “expert clients”. Then, as soon as someone was diagnosed to be HIV positive, we linked them with an “expert client”. Your expert client would take you for your first, or if you wanted, subsequent clinic visits. Having someone accompany you for your first clinic visit proved to be an important thing. We got our linkage rates to care from less than 30% up to over 91% in two years with this program.

Now that Eswatini has achieved 95-95-95, is the feeling that it can continue this program with its own internal organizations and people?

What we have now is a five-year plan. We call them cooperative agreements. And what we're looking at is a transition to sustainability. Essentially, we're helping the Ministry of Health to have the capacity to do the implementation without depending on external partners.

Are there concerns that even if you transfer all the capacity, but the money goes away, that the program won't be sustainable?

The Government of the Kingdom of Eswatini used to purchase all first-line antiretrovirals. However, this year, because of the decreased economy due to COVID-19, they can't afford to do that.

In terms of COVID-19 complications, is it mostly just the money or have other complications arisen?

We've had two waves. After the first wave, people were very hesitant to go to clinics to pick up their ARVs and we didn't want to congest the clinics with non-COVID patients. So, we set up community distribution, and we made it not just for antiretrovirals, but for all drugs that might be needed if you weren't sick with COVID. And we to switched to dispensing a six month supply of drugs to patients.

It sounds like you were very responsive and able to adapt programs to meet these new challenges.

Understanding the country and engaging different governmental and non-governmental entities has been very helpful. For example, we realized that faith-based organizations are very important in Eswatini. One group of the key influencers are pastors and religious leaders. So, we have something called the Faith and Community Initiative.

Because people couldn't get tested for HIV during this time in clinics, we provided self-test kits to religious leaders in churches. And we trained the religious leaders in HIV prevention. They had specific messages that they incorporated into their sermons and trainings with youth and other groups.

And now we're incorporating messages to explain and promote COVID-19 for vaccinations. We’re looking to set up the same kind of systems outside of facilities for COVID-19 vaccination.

Are there any learnings from your time in Eswatini you're going to take into your new role in Ethiopia?

I'm hoping some of the lessons we've learned around COVID-19 will be helpful for Ethiopia. What we learned in the second wave, when we had the fourth highest death rate in Africa from COVID-19, was that COVID-19 illness requires a level of care at the health facility level that is critical care, almost tertiary care. Our health centers were really designed for primary healthcare. It’s very different healthcare training, equipment, and supplies that you need for critical care.

One of the things that really helped us was the infrastructure that was developed under PEPFAR. All the equipment and trained human resources that provided HIV viral loads, we could use that for COVID-19 testing. The clinical information systems we had put in place could now also help us monitor the volumes of COVID-19 patients and the PPE and clinical needs at the facility level. The supply chain logistics we had put in place for ARVs were instrumental for getting urgent oxygen and PPEs out to needed facilities.

This is a big question, but what do you believe is the most pressing global health issue today, and what can we be doing about it?

I think COVID-19 is as well as our understanding of how we respond to these kinds of pandemic emergencies and what kinds of systems we should have in place. There’s lots of opportunities to use the infrastructures that were developed under PEPFAR, whether it's information systems, laboratory systems, training systems, and supply chain management systems.

In Ethiopia, you have a much broader spectrum of health topics you'll be focused on. Which one of them are you most passionate about?

My biggest passion is HIV care and prevention. But if the urgency is something else, then I think I might have to focus on that. So, I think my response would be, whatever's the urgent issue, that would be my passion. 

By Amy Frances Goldstein