HIV and AIDS in Swaziland

In Swaziland, a small landlocked country in Southern Africa, one in four adults are living with HIV. Since the first cases of AIDS were reported in the country in 1986, the virus has spread at an alarming rate and now Swaziland has the highest HIV prevalence in the world.1 Women have been particularly affected by the epidemic; among those aged 15-49 HIV prevalence is 31 percent among women, compared to 20 percent among men.2

AIDS has devastated the country. Orphans and vulnerable children account for an estimated 15 percent of the total population3 and in 2009 around 7,000 adults and children died from AIDS.4 The impact of Swaziland's epidemic has been so severe that life expectancy is just 49 years - one of the lowest in the world.5

The long-term survival of Swaziland as a country will be seriously threatened if the spread of HIV is not halted.6

back to top The history of AIDS in Swaziland

In the mid-1980s, Swaziland's government responded to its country's first cases of AIDS by setting up the Swaziland National AIDS programme (SNAP). SNAP introduced a short-term plan for 1986 to 1988, and later a medium-term plan, which lasted from 1989 to 1992. Both these campaigns aimed to provide information and education on HIV; promote condom use; manage the spread of sexually transmitted infections; and screen all donated blood. HIV surveillance was introduced in 1992, and by that time 3.9 percent of pregnant women were HIV positive.7

Map of Swaziland including population and life expectancy  

In 1993 the HIV/AIDS programme was restructured, and subsequently the national strategic plans of 1994-1997 and then 1998 to 2000 were developed.8 In 2005 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.9 However it is unclear how much was actually achieved at this time, as by 1996 HIV prevalence among pregnant women had increased rapidly to 26.3 percent.10

By 1998 a new policy document on HIV/AIDS Prevention and Control contained plans to make education and communication “the major weapon” against HIV and AIDS. The plans also aimed to improve care for those living with HIV; increase women’s access to prevention services; scale up testing services; and further prevent the spread of STDs.11

In 1999 the King declared AIDS a national disaster.12 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 2000–2005.13 This focused on improving health services; changing behaviour through mass media outlets, schools and workplaces; and minimizing the future impact of the epidemic, especially for vulnerable groups such as orphans.

The government announced in the strategic plan that 2000 and beyond “will be the time of delivery” for HIV/AIDS policy in Swaziland.14 This statement suggests previous efforts were ineffective in delivering the necessary change, and indeed by 2000 HIV prevalence was 34.2 percent for pregnant women in Swaziland.15

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 National Strategic Framework 2009-2014.

When a severe drought hit Swaziland in 2004, the government declared another national disaster and appealed for humanitarian aid.16 At a press conference, Prime Minister Themba Dlamini declared:

"The Kingdom of Swaziland is seriously facing a humanitarian crisis that stems from three adjoining fundamental trends, namely drought and land degradation, increasing poverty and HIV/AIDS."17

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 percent in 2004, to 39.2 percent. NERCHA’s director, Derek von Wissell, said in 2006,

“We are cautiously optimistic that our prevention strategies are beginning to take hold”.18

In 2009, the United Nations Development Programme in Swaziland affirmed that although an increase in HIV prevalence among pregnant women was noted from 2006-2008 the increase was 'not significant.'19 According to their analysis, this slight increase compared with the rapid rise in the 1990s and then decrease from 2004-2006, could be seen as indicative of stabilisation of HIV prevalence overall.

back to top The current situation in Swaziland

Graffiti in Swaziland near to signs by a church saying Graffiti in Swaziland near to signs by a church saying "Your safety is in Jesus"

In February 2010, UNAIDS Executive Director Michel Sidibe visited Swaziland where he presented a report estimating that three in every 100 people in Swaziland will be infected with HIV every year leading to an expected 18,000 new infections each year by 2012.20 Although he praised prevention of mother-to-child transmission initiatives, much progress remains to be made.

At the beginning of 2011 Swaziland launched an initiative to circumcise between 125,000 and 175,000 HIV negative males from 15 to 49 years of age in a 12-month period. The ambitious plan was based on mathematical modelling studies suggesting that male circumcision for HIV prevention could reduce annual HIV incidence in Swaziland by 75 percent by 2025.21 Nevertheless, figures released in 2011 show Swaziland has a long way to go; the number of circumcision performed in 2010 only reached a total of 18,896.22

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, 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.

The deaths of many adults have left behind a youthful population in Swaziland. Around 39 percent of the population are under 14, and those over 65 only account for 3.7 percent.23 Many children are orphaned and left in the care of grandparents and if they do not have any, they may be left to fend for themselves. Increasing economic decline may push Swazis into further poverty or economic migration, potentially escalating the scale of the epidemic. 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.

back to top HIV testing in Swaziland

“The government estimates that only 15 percent of people aged 15-49 years old have been tested for the virus.”

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 16 percent of people aged 15-49 years old have been tested for the virus and know their results.24 Swazi traditional opinion links AIDS with sexual promiscuity, and often causes HIV positive people to be rejected by their families.25 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 practice of widow inheritance, or marrying his deceased brother’s wife.26 However, attitudes 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.27

At the end of 2003, Swaziland had 13 sites providing voluntary counselling and testing (VCT); by 2007 there were 110 sites and by 2010 this number had significantly increased to 198.28 29 Although the number of HIV tests carried out per 100,000 of the population (over 15 years) increased to 251 in 2009, the number of HIV tests decreased to 243 per 100,000 population in 2010.30 31 32 With a population of around 1.2 million people, only 148,072 adults (over 15 years) receiving HIV testing and counselling indicates that 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.

In April 2009 a new national testing initiative partly funded by PEPFAR and supported by UNAIDS, was introduced. The campaign, called the 'love test', is hoped to bring about behaviour change in the country and encourage couples to get tested together in an act of devotion to each other. The idea is to stop the trend of individuals not disclosing their status to their partner and contributing further to the spread of HIV.33

Population Services International, a reproductive health NGO, is targeting public transport workers including taxi drivers in a nationwide campaign to get this high-risk but neglected group of the population tested. Drivers and bus conductors often spend long hours on the road and have little knowledge about HIV and AIDS. In response, PSI has set up VCT centres at their workplaces in taxi and bus terminals around the country. Bongiwe Zwane, PSI's Public Relations Coordinator, has commented on the success so far…

"We haven't had any problems with the taxi men. This is something that's long overdue - they appreciate the attention. The response to testing has been great, just great.”34

back to top HIV prevention in Swaziland

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

Condom distribution

Condom education at a youth club in Swaziland Condom education at a youth club in Swaziland

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 7 million.35 Female condoms have also been distributed, but much less widely- around 312,000 were handed out in 2008.36

In spite of their good supply in Swaziland, the use of condoms remains controversial and unpopular. In the 2006/7 Swaziland Demographic and Health Survey around half of sexually active respondents aged 15-49 admitted to engaging in non-regular sex without using condoms.37

"Men in Swaziland do not use condoms. They are distributed all over, but they are not used."Hannie Dlamini, AIDS activist and health motivator38

Although the government has encouraged condom use, some influential community leaders have undermined the government's message. Hannie Dlamini once stated that "condoms don't stop AIDS" and only "faithfulness and abstinence stop AIDS".39 Religious and traditional leaders have also described condoms as “unSwazi”.40

In 2009 the AIDS Healthcare Foundation (AHF) launched a free condom and HIV testing campaign in Manzini. The condoms, branded 'Love Condoms' received a large amount of attention:

"The demand for our 'Love Condoms' is overwhelming: all the people who have seen us on TV and in the paper are asking for these condoms".Dr. Nduduzo Dube, Medical Director, Lamvelase Help Centre, Manzini41

It is hoped the campaign will encourage and popularize the use of condoms in the country.

Behaviour change campaigns

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.42 The policy, which required all girls to wear tassels to display their virginity, was widely criticised for demeaning girls and blaming women for the spread of HIV.43 Interestingly, the King was accused of ignoring his own policy when, in 2001, he became engaged to a 17 year old girl.44 In 2005, the King called an end to the policy.45 Generally King Mswati has been praised for speaking out about HIV/AIDS, however community organisations have said his sexual practices set a poor example. The King has numerous wives in accordance with the Swazi tradition of polygamy.

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”.46 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.47

In an attempt to combat the common Swazi practice 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.48 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”.49

HIV education poster in Swaziland HIV education poster in Swaziland

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.50 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.51

Latest country data on sexual behaviour is promising; only 6 percent of women and men aged 15-49 reported having sex with more than one partner in the 12 months prior to the study.52 Yet, there is a distinct difference between men and women, with men ten times more likely to engage in sex with multiple partners. Swaziland's government recognise the need for increased positive behaviour change in order to tackle the epidemic:

"Adopting positive behaviour change was and continues to be a major challenge in the country".53

However, behaviour change will take a long time. The subordinate status of women and high unemployment forces vulnerable women to turn to sex work or offer sex to older men in exchange for money or gifts. Due to traditions such as polygamy, young women marry older men with whom they will not be able to insist on condom use. Such situations are not easy to change in a very traditional society. As one community leader has noted:

“This is a long-term matter...It is time we stopped treating AIDS in Swaziland as an emergency and see it as it is: a decades-long situation.” 54

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 into all health facilities that offered antenatal care.55

Swaziland began to receive funding to implement PMTCT programmes through the Elizabeth Glaser Pediatric AIDS Foundation in 2004.56 These programmes include training healthcare workers, scaling up voluntary testing and counselling services and supplying free nevirapine. As of March 2009, the Foundation had provided nearly 69,000 women with access to PMTCT services.57

At the end of 2004, there were 44 PMTCT sites throughout the country; this increased to 132 in 2008.58 By 2010 around 83 percent of pregnant women were tested for HIV and more than 95 percent of those testing positive received antiretrovirals to prevent the transmission of HIV to their baby.59

Swaziland has further succeeded in delivering effective PMTCT services by completely phasing out the use of single-dose nevirapine in 2010.60 Nevertheless, an estimated 1,300 children were newly infected with HIV in 2010, indicating Swaziland must maintain its commitment to testing pregnant women and delivering treatment to those found to be living with HIV.

back to top HIV and AIDS treatment in Swaziland

In 2003 the government launched its strategy to provide free nationwide antiretroviral treatment (ARVs).61 In 2005 many hospitals ran out of drugs, some for as long as three weeks.62 This greatly undermined efforts to improve treatment provision, as a break from taking ARVs regularly can cause HIV to become resistant to treatment.

At the end of 2009, antiretroviral therapy had become available at 89 health facilities across the country and just over 47,000 people were receiving ARVs.63 By 2010 antiretroviral therapy had become increasingly available, with an estimated 59,802 out of the 83,000 people needing treatment receiving it.64 This means that 72 percent of those in need are currently receiving antiretroviral treatment. Despite notable improvements in making treatment more accessible, these gains have only benefited adults living with HIV. Access to treatment for children continues to be inadequate, with only 55 percent of children eligible for treatment receiving it.65

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 and care. Around 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.66 There are only 2 physicians available for every 10,000 people, and one nurse for every 356 people in Swaziland.67 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.68 In addition, the government have been slow to implement 'task-shifting' programmes. These programmes increase the distribution of antiretroviral drugs as they allow nurses to carry out routine prescription duties that would normally be carried out by doctors.69

Another obstacle to the provision of effective treatment in Swaziland is the pervasive belief in witchcraft and the trust placed in traditional health practitioners of which there are more than 8,000 in Swaziland. According to a 2008 government report, some people are tempted to replace ARVs with medicines provided by these health practitioners, reducing levels of treatment adherence.70

back to top The future

Although progress has been made with regards to treatment and PMTCT, poverty, gender inequality and harmful cultural practices continue to contribute to a high risk of HIV infection among the general population.71 There is still an urgent need for effective prevention initiatives, including a greater focus on improving access to HIV testing facilities. The extremely high rate of tuberculosis (TB) co-infection with HIV is also a major concern and the main cause of mortality in the country.72

Swaziland's King has been criticised for his "blatant disregard" for the factors contributing to the AIDS epidemic in his country and living a lavish lifestyle, while his country is in such a dire situation. When the King chartered a plane to take his 13 wives on an international shopping trip in 2008, hundreds of Swazi women protested, shouting "we need to keep that money for ARVs!".73 74 In 2010 Prince Mangaliso, chairman of the king's advisory council, claimed pharmaceutical companies were exaggerating the HIV/AIDS epidemic to "keep their businesses afloat".75

It appears that stronger action from King Mswati and his government is needed in order to dramatically cut HIV transmission rates in one of the world's worst AIDS epidemics.

References back to top

  1. Government of the Kingdom of Swaziland (2010, March) 'Monitoring the declaration of commitment on HIV/AIDS (UNGASS) Swaziland country report'
  2. Government of the Kingdom of Swaziland (2010, March) 'Monitoring the declaration of commitment on HIV/AIDS (UNGASS) Swaziland country report'
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  5. CIA World Factbook (2011) 'Life expectancy at birth'
  6. UNDP (2005) 'Country programme document for Swaziland (2006-2010)'
  7. Kingdom of Swaziland, Ministry of Health and Social Welfare (2002) '8th HIV sentinel serosurveillance report'
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  9. [PDF] WHO (2005) 'Summary country profile for HIV/AIDS treatment scale-up'
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  11. [PDF] Government of the Kingdom of Swaziland (1998) 'Policy Document on HIV/AIDS and STD Prevention and Control'
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  13. [PDF] Swaziland Government Deputy Prime Minister’s Office (2000, September) 'Swaziland National Strategic Plan for HIV/AIDS 2000-2005'
  14. [PDF] Swaziland Government Deputy Prime Minister’s Office (2000, September) 'Swaziland National Strategic Plan for HIV/AIDS 2000-2005'
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  18. IRIN (2006, December) 'Has Swaziland turned the corner in the fight against AIDS?'
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  34. IRIN (2010, March 23rd) 'Swaziland: Taxi Drivers Get Tested
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  36. PlusNews (2009, 10th September) 'Southern Africa: What of the female condom?'
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  39. IRIN (2003, 2nd December) 'Resisting condoms as AIDS deaths soar'
  40. IRIN (2003, 2nd December) 'Resisting condoms as AIDS deaths soar'
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  49. ICW (2006, 26th July) 'ICW dismayed at recent prevention campaign in Swaziland'
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  68. Kober, K and Van Damme, W, (2006) 'Public sector nurses in Swaziland: can the downturn be reversed?'
  69. IRIN (2010, 3rd September) 'Task-shifting could improve HIV treatment and prevention'
  70. The International Treatment Preparedness Coalition (2010, April) 'Rationing Funds, Risking Lives: World backtracks on HIV treatment'
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  72. Médecins Sans Frontières (MSF) (2010) 'Fighting a dual epidemic'
  73. BBC (2008, 21st August) 'Swazi anger at royal wives' trip'
  74. Patterson, A.S (2006) 'The politics of AIDS in Africa', Lynne Rienner Publishers; Boulder/London
  75. The Times of Swaziland (2010, 17th August) 'I'm not scared of HIV - Logcogco'