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Swaziland, a small country in Southern Africa, has the world’s highest adult HIV prevalence rate of 33.4%, and AIDS has devastated the ‘tiny Kingdom’.¹ Average life expectancy has dropped from 57 to just 31 years of age, 600,000 children have been orphaned, and 16,000 adults and children died from AIDS in 2006 alone.²,³ Current trends show that levels of HIV are increasing despite efforts to increase HIV prevention.⁴

History of AIDS in Swaziland

Swaziland’s first AIDS case was reported in 1987. The government responded by setting up the Swaziland National AIDS programme (SNAP). SNAP introduced the short-term plan of 1986 to 1988 and later a medium-term plan, which lasted from 1989 to 1992. Both these campaigns provided information and education on HIV/AIDS, promoted condoms, attempted to manage the spread of sexually transmitted infections and screen all donated blood. HIV surveillance was introduced in 1992, and by that time 3.9% of pregnant women were HIV positive.⁵

In 1993 the HIV/AIDS programme was restructured, and subsequently the national strategic plans of 1994-1997 and then 1998 to 2000 were developed.⁶ Recently the World Health Organisation (WHO) described the Swaziland government as having “a high level of political commitment” to fighting the spread of HIV since the start of the epidemic.⁷ However it is unclear how much was actually achieved at this time, as HIV prevalence for pregnant women increased rapidly to 26% by 1996.⁸

By 1998 a new policy document on HIV/AIDS Prevention and Control planned to make education and communication “the major weapon” against HIV and AIDS. It also aimed to improve care for those living with HIV and women’s access to prevention services, to scale up testing services and further prevent the spread of STDs.⁹

In 1999 the King declared AIDS a “national disaster”. As a result the Crisis Management and Technical Committee (CMTC) was set up to lead the national response. The CMTC developed the National Strategic Plan for 2000–2005. This focused on behaviour change communication distributed through national media and in schools and workplaces, improving health services and minimizing the future impact of the epidemic especially for vulnerable groups such as orphans.¹⁰

The government announced in the strategic plan that 2000 and beyond “will be the time of delivery” for HIV/AIDS policy in Swaziland.¹¹ This statement suggests previous efforts were ineffective in delivering the necessary change, and indeed by 2000 HIV prevalence was 34.2 % for pregnant women in Swaziland.¹²

In 2001, NERCHA, or the National Emergency Response Council on HIV and AIDS replaced the CMTC. NERCHA is responsible for mobilizing an expanded response to the epidemic, in line with the Second National Multisectoral HIV and AIDS Strategic Plan of 2006 to 2008.¹³

Hopes were raised in 2006, when the government announced a slight decline in Swaziland’s HIV prevalence rate among pregnant women, which had dropped from 42.6% in 2004, to 39.2%. NERCHA’s director, Derek von Wissell, said in 2006, “We are cautiously optimistic that our prevention strategies are beginning to take hold”.¹⁴

HIV Prevention initiatives

The Swazi government has introduced a number of initiatives for HIV prevention such as condom distribution, behaviour change campaigns, prevention of mother to child transmission, and early diagnosis by testing.¹⁵

Condom distribution

Condoms have been widely available in Swaziland since the 1990s. The government and other agencies made over one million male condoms available in 2000, and by 2004 this number had grown to over 6 million. Female condoms have also been distributed, but much less widely- fewer than 20,000 were supplied in 2004. Free condoms have also been made available at key locations in and around border posts designed to target some of the most at risk groups such as migrant workers, truck drivers and female sex workers.¹⁶ The government plans to make 10 million male condoms and 80 thousand female condoms available by 2008.

In spite of their good supply in Swaziland, the use of condoms remains controversial and unpopular. The government has encouraged condom use, however influential community leaders have undermined this message, such as the leading AIDS campaigner Hannie Dlamini, who claimed that abstinence should be the major focus of a prevention campaign. Religious and traditional leaders have also described condoms as “unSwazi”.¹⁷

The Behavioural Surveillance Survey of 2002 showed that among at risk populations condom use was relatively high; female sex workers reported 90% use with their last partner, for example. Generally the level of condom use in the main population was low with regular partners, and more common with non-regular partners.¹⁸

Behaviour change campaigns

“It is enormously disappointing that education and prevention initiatives have had so little effect”, Prime Minister Sibusiso Dlamini, 2002.¹⁹

HIV education campaigns in Swaziland initially focussed on encouraging condom use, but in more recent years have moved towards abstinence as the best form of HIV prevention.

In 2001 King Mswati III reinstated a custom that banned all girls under 18 from sexual activity for five years, and required any man who has sex with a virgin to pay a cow to the girl's family. All girls were made to wear tassels to display their virginity. Interestingly, the King himself broke this policy by becoming engaged to a 17 year-old girl. This action brought accusations of hypocrisy, and the policy was also criticized for demeaning girls and for blaming women for the spread of HIV.²⁰ Generally the King has been praised for speaking out about HIV/AIDS, however community organisations have said his sexual practices set a poor example. The King has thirteen wives in accordance with the Swazi tradition of polygamy.²¹

In 2005 a campaign targeting young people was launched through billboard adverts, radio and the printed press with slogans such as, “Because tomorrow is mine”, and, “I want to finish my education. Sex can wait”.²² The UN has reported that almost two in three female Swazi secondary school students are following this advice and abstaining from sex until their late teens, however when they do become sexually active they face huge risks of acquiring HIV.²³

In an attempt to combat the common Swazi practise of multiple partners, NERCHA launched a public HIV awareness campaign in 2006 under the siSwati title, “Makhwapheni Uyabulala”, or, “Your secret lover will kill you”. Makhwapheni refers specifically to the ‘secret lovers’ of women.²⁴ This focus met widespread criticism for its moralistic message that blamed women for the HIV epidemic and portrayed them as sexually irresponsible. The International Community of Women Living with HIV/AIDS claimed that the campaign “failed to meaningfully involve people living with HIV/AIDS”.²⁵

According to NERCHA, this approach was a reaction to the “vague, unfocussed billboard messages” of the past that “pussyfooted” around sex. Despite its controversy however, the campaign did provide fresh interest in the HIV issue by forcing people to confront how HIV is passed on.²⁶ Interestingly, among Swazis surveyed by USAID, 86 percent had heard of the makwapheni campaign; 91 percent agreed with its message; and 78 percent said it made them consider changing their sexual behaviour.²⁷

Overall, behaviour change campaigns have not had the desired effect of encouraging Swazis to use condoms or reduce numbers of sexual partners. The behavioural surveillance survey of 2002 found that risk-taking behaviour was common, despite good knowledge of how HIV is transmitted. In 2002 the mean age of sexual debut among in school youth was 16.3 years, and 29% to 58% of the groups surveyed reported having a non-regular partner in the last 12 months.²⁸

“so far national efforts to address this (AIDS) challenge have only yielded heightened awareness of the problem but have failed to stimulate levels of sexual behaviour change that are necessary for turning the epidemic around” - Swaziland government, 2006.

Prevention of Mother to Child Transmission (PMTCT)

Swaziland’s programme for the prevention of mother to child transmission of HIV (PMTCT) was launched in 2003, with the target of integrating PMTCT services in all health facilities that offered antenatal care. By the end of 2004, there were 16 PMTCT sites throughout the country; this increased to 44 in September 2005.

Swaziland began to receive funding to implement PMTCT programmes through the Elizabeth Glaser Pediatric AIDS Foundation in 2004. These programmes include training healthcare workers, scaling up voluntary testing and counselling services and supplying free nevirapine.²⁹

In 2006 15,000 Swazi children aged up to 14 years of age were living with HIV. ³⁰ By 2008 the government aims to reduce the proportion of children under 4 years old who are HIV positive by 30%.

Read about AVERT’s campaign to scale up services for prevention of mother to child transmission of HIV worldwide.

HIV Testing

The enormous stigma associated with HIV and AIDS in Swaziland prevents many Swazis from being tested for HIV or declaring their HIV status if they are positive. The government estimates that only 20% of people in the country know their HIV status. Swazi traditional opinion links AIDS with sexual promiscuity, and often causes HIV positive people to be rejected by their families.³¹ It is believed that many people in the country do not want to know their HIV status, and those who do know will often keep it a secret, some even from their sexual partners.

Prominent Swazi figures have been slow to talk publicly about their HIV status. The first traditional healer to admit that he was HIV positive was Chief Madelezi Masilela, who acquired HIV through the practise of widow inheritance, or marrying his deceased brother’s wife.³²

Attitudes though are gradually changing. In 2007, banking executives and workers from Nedbank and Standard bank publicly took HIV tests in Mbabane. This move was followed by 20 pastors who also declared the fact they had been tested.³³

At the end of 2003, Swaziland had 13 sites providing voluntary counselling and testing (VCT); by December 2005 there were 37 sites.³⁴ The number of people accessing VCT services increased from 13,576 in 2003 to 95,000 in September 2005.³⁵

Despite these improvements, coverage is still inadequate. Huge demand and long waiting times overload counsellors, which reduces quality. Since most testing sites are in major urban centres, people from rural areas must travel long distances to access services, or not get tested at all.

By 2008 the government aims to increase the proportion of adults aged 15 to 49 who have ever tested for HIV to 40%, and to increase the proportion of adults who know their status to 30%.

HIV & AIDS Treatment

In 2003 the government launched its strategy to provide free nationwide antiretroviral treatment (ARVs). That year approximately 660 people, or 1.7 per cent of the demand, were receiving antiretroviral therapy from the one site to offer it at Mbabane general hospital.

By June 2004, 3200 people were receiving ARV treatment,³⁶ and by December 2005, Swaziland had increased treatment provision to 13,000 people at 17 different health facilities.³⁷ Antiretroviral therapy had become available at all six public hospitals in the country, at five public health centres and at six facilities in the private sector.³⁸ The government now plans to increase the number of HIV positive people receiving ARVs by approximately 13,000 new patients per year.

Despite these successes and the high level of funding for HIV treatment in Swaziland, limited infrastructure and human resources hinder the delivery of effective treatment. 80 percent of the population lives within 8 kilometres of a facility that provides at least antenatal care, however access for rural communities is limited. There are only 2 physicians available for every 10,000 people, and one nurse for every 356 people in Swaziland.³⁹ The recruitment and retention of staff is constrained by poor working conditions, few incentives and low pay, and the availability of health staff is declining further due to HIV related illness and deaths.⁴⁰

In 2005 many hospitals ran out of drugs, some for as long as three weeks.⁴¹ This greatly undermined efforts to improve treatment provision, as a break from taking ARVs regularly can cause HIV to become resistant to treatment.

The impact of HIV and AIDS in Swaziland

As elsewhere in sub-Saharan Africa, the huge number of people dying from AIDS in Swaziland exacerbates existing poverty, which in turn leaves individuals vulnerable to the adverse affects of HIV. When those of productive age die from AIDS or are too sick to work, this means there is less income and therefore less food for families. Lack of adequate food and nutrition leaves individuals less able to cope with HIV if they are infected, as effective treatment depends on a good diet.⁴² Poor and vulnerable women are more likely to engage in transactional sex, where they have no power to negotiate condom use.⁴³

The deaths of many adults have left behind a youthful population in Swaziland. 46% of the population are under 15, and those over 65 only account for 3%. Many children are orphaned and left in the care of grandparents if they have them. Otherwise, they may be left to fend for themselves, as children are in charge of 15,000 households in Swaziland.⁴⁴ In total the country has 63,000 AIDS orphans.⁴⁵ Increasing economic decline may push Swazis into further poverty or economic migration, potentially escalating the scale of the epidemic.⁴⁶

The huge scale of AIDS-related illness and deaths is weakening the government’s capacity to deliver healthcare and other services, with serious consequences for food security, economic growth and human development. The long-term survival of Swaziland as a country will be seriously threatened if the spread of HIV is not halted.⁴⁷

The future

The Swazi government has admitted a “lack of seriousness” in dealing with the AIDS crisis. Only 0.25% of the national budget is allocated to the AIDS epidemic, despite its classification as one of three national priorities and the declaration of AIDS as a national disaster. Stronger action from King Mswati and his government is needed for prevention measures, including more open debate on the issue of HIV.

International observers have commented that the government’s tight control of the media has restricted debate around the HIV/AIDS epidemic. Many Swazis receive information through the radio, and HIV related communication is often pushed back to unpopular health related programmes.⁴⁸ By contrast, Uganda staged a highly successful HIV prevention programme based around a liberalised national press. In that country the issue of HIV/AIDS was opened for public debate, which allowed for NGOs and private organisations to advocate their own messages about HIV/AIDS prevention.⁴⁹

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