SIDA y VIH
HIV and AIDS in Swaziland
In Swaziland, a small landlocked country in Southern Africa, one in four people 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 26.1% of the country's adult population are infected - the highest HIV prevalence rate worldwide.1 Women have been particularly affected by the epidemic; among those aged 15-49 HIV prevalence among women is 31%, compared to 20% among men.2
AIDS has devastated the country. Around 10,000 adults and children died from AIDS in 2007 alone, around 15,000 Swazi children aged up to 14 years are living with HIV, and an estimated 56,000 children have been orphaned by AIDS.3 The impact of Swaziland's epidemic has been so severe that life expectancy has dropped to just 32 years - the lowest in the world.4
The long-term survival of Swaziland as a country will be seriously threatened if the spread of HIV is not halted.5
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% of pregnant women were HIV positive.6
In 1993 the HIV/AIDS programme was restructured, and subsequently the national strategic plans of 1994-1997 and then 1998 to 2000 were developed.7 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.8 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%.9
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.10
In 1999 the King declared AIDS a national disaster.11 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 2000–2005.12 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.13 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.14
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.
When a severe drought hit Swaziland in 2004, the government declared another national disaster and appealed for humanitarian aid.15 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." - 16
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”. - 17
In 2009 the 11th HIV sentinel survey of pregnant women showed a stabilization of Swaziland's epidemic, although HIV prevalence was still alarmingly high.18
The impact of HIV and AIDS in Swaziland
Graffiti in Swaziland near to signs by a church saying
"Your safety is in Jesus"
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% of the population are under 14, and those over 65 only account for 3.7%.19 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.
HIV testing in Swaziland
“The government estimates that only 15% 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 15% of people aged 15-49 years old have been tested for the virus.20 Swazi traditional opinion links AIDS with sexual promiscuity, and often causes HIV positive people to be rejected by their families.21 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.22 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.23
At the end of 2003, Swaziland had 13 sites providing voluntary counselling and testing (VCT); by 2007 there were 110 sites and by 2008 this number had significantly increased to 170.24 The number of HIV tests carried out per 1000 population also increased from 90 in 2007 to 139 in 2008.25 However, 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.
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.26
HIV prevention initiatives
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
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.27 Female condoms have also been distributed, but much less widely- around 312,000 were handed out in 2008.28
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.29
"Men in Swaziland do not use condoms. They are distributed all over, but they are not used." - Hannie Dlamini, AIDS activist and health motivator30
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".31 Religious and traditional leaders have also described condoms as “unSwazi”.32
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, Manzini33
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.34 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.35 Interestingly, the King was accused of ignoring his own policy when, in 2001, he became engaged to a 17 year old girl.36 In 2005, the King called an end to the policy.37 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”.38 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.39
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.40 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”.41
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.42 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.43
Latest country data on sexual behaviour is promising; only 6% of women and men aged 15-49 reported having sex with more than one partner in the 12 months prior to the study.44 However, 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". - 45
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.46
By the end of 2004, there were 44 PMTCT sites throughout the country; this increased to 110 in 2006.47 By the end of 2008 around 78% of pregnant women were tested for HIV and most of those testing positive received antiretrovirals for preventing HIV transmission to their baby.48
Swaziland began to receive funding to implement PMTCT programmes through the Elizabeth Glaser Pediatric AIDS Foundation in 2004.49 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.50
Read about AVERT’s campaign to scale up services for prevention of mother-to-child transmission of HIV worldwide.
HIV & AIDS treatment in Swaziland
In 2003 the government launched its strategy to provide free nationwide antiretroviral treatment (ARVs).51 In 2005 many hospitals ran out of drugs, some for as long as three weeks.52 This greatly undermined efforts to improve treatment provision, as a break from taking ARVs regularly can cause HIV to become resistant to treatment.
By 2006, 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.53 Just under 33,000 people were receiving ARVs by the end of 2008.54
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. 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.55 There are only 2 physicians available for every 10,000 people, and one nurse for every 356 people in Swaziland.56 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.57
Swaziland's King has often been criticised for leading a lavish lifestyle, when 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!".58
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.59 There is still an urgent need for effective prevention initiatives, including a greater focus on improving access to HIV testing facilities.
Swaziland's King has been criticised for his "blatant disregard" for the factors contributing to the AIDS epidemic in his country.60 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.
