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HIV & AIDS in Swaziland

SWAZILAND - 2012 Statistics<br/>Number of people living with HIV: 210,000 | Adult HIV prevalence: 26.5%

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 at 26 percent. 1

Graffiti near a church saying 'A prayer alone will not stop HIV', in SwazilandHIV and AIDS have had a devastating impact on the country; particularly among families and households, with 6,813 adult and child AIDS-related deaths in 2011. 2 According to the latest figures, life expectancy is just 48.9 years – one of the lowest in the world. 3 As elsewhere in sub-Saharan Africa, the impact of so many AIDS-related deaths in Swaziland exacerbates existing poverty for families, and has resulted in a very youthful population. More than a third of the population are under 14 years old, and only 5.9 and 4.7 percent females and males respectively are over 65. 4 It has resulted in a number of children becoming orphaned or vulnerable (OVC); in 2010 an estimated 104,026 children were classified as being OVC. 5 With such high prevalence amongst the most productive working age ranges, responsibility for the care of orphaned and vulnerable children often falls upon older generations, such as grandparents.

Currently, Swaziland is one of just five sub-Saharan African countries to achieve the target of getting more than 80 percent of eligible people on antiretroviral treatment (ART). 6 Among pregnant women, treatment access is also high at 83 percent. 7 Consequently, the number of AIDS-related deaths in Swaziland is declining. 8

Vulnerable groups at risk of HIV infection include: sex workers, migrant populations, prisoners, men who have sex with men (MSM) and injecting drug users (IDUs). Latest estimates show that two in three female sex workers are living with HIV, expressing the lack of access to HIV services such groups experience. 9 Gender based violence is also still rife; around a third of adults believe violence against a woman is justified in certain instances. 10 This emphasises the continued vulnerability of Swazi women and their lack of rights, which increases their risk of HIV infection. If new HIV infections are to be prevented, access to HIV services and human rights issues such as gender equality must be addressed, especially amongst vulnerable groups. Fortunately, Swaziland’s Ministry of Health developed a framework in 2011 to put a special focus upon ensuring access to prevention and treatment amongst most-at-risk groups (MARPs). 11

HIV testing in Swaziland

In recent years, the number of people (aged 15-49 years) testing for HIV, and receiving their results, has rapidly increased; from 16 percent in 2009 to an estimated 40 percent in 2011. 12 Although this indicates a considerable improvement in the accessibility and acceptability of HIV testing, efforts must continue to encourage testing uptake.

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. Swazi traditional opinion links AIDS with sexual promiscuity, and often causes HIV-positive people to be excluded from family activities. 13 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. 14 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. 15

Latest figures also show that public attitudes to testing are now becoming more positive. Interestingly, the recent increase in testing has been mirrored by a decline in HIV-related stigma. The 2011 Stigma and Discrimination Index, which gauged attitudes towards people living with HIV, found that although stigma has decreased, self stigma among people with HIV remains common. 16 This could explain why people are more willing to be tested, but less willing to inform others if they receive a positive test result. Nevertheless this shows the country has made incredible progress in tackling stigma- a huge barrier to HIV testing.

At the end of 2003, Swaziland had just 13 sites providing voluntary counselling and testing (VCT). 17 In 2006 a provider-initiated approach to HIV Testing and Counselling (HTC) became mainstream; by incorporating it into the general health care system, more people could be reached than via VCT. 18 Supported by 210 HTC sites and 40 outreach sites, the number of HIV tests carried out over 2010 and 2011 remained fairly stable at around 245-250 per 100,000 of the population, aged over 15 years. 19 20 21

HIV testing at a rural clinic in SwazilandIt is clear that Swaziland’s commitment to HIV testing has achieved great results and with HTC implemented in 76 percent of health care facilities it is likely that HIV testing uptake will continue to rise. 22 However, a number of barriers remain. The concentration of HTC services in urban centres is a major barrier to increasing HIV testing in rural communities. 23 To address this problem, 360 KaGogo Community Centres have been built in rural areas of Swaziland. These are traditional built and run centres where people go to take part in meetings and forums about HIV in their community, and where data can be collected which is sent to NERCHA. 24 Furthermore, the quality of HTC services must remain high to encourage patients to return to receive treatment and further testing, rather than not returning after their initial test. However, the high demand upon clinics can adversely affect the quality of HTC services when doctors have an overload of patients. 25 Task-shifting initiatives which allow nurses to administer first line treatment have helped doctors cope with this pressure. 26

Targeting individuals who may be at an increased risk of HIV infection, such as sex workers, MSM, IDUs, prisoners and public transport workers should be central to any national testing campaign. One nationwide testing campaign, led by Population Services International (PSI), targeted public transport workers, such as taxi drivers, 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 set up VCT centres within taxi and bus terminals around the country.

“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.” 27

HIV prevention in Swaziland

The Swazi government has introduced a number of initiatives for HIV prevention, such as condom distribution and behaviour change campaigns, as well as scaling-up promotion of PMTCT. Nationwide prevention strategies have been positively received in the years 2010-2012. 28 Enacting behaviour change through education is now seen as the major challenge to prevent HIV among individuals.

Swaziland's HIV initiative suggests that male circumcision for HIV prevention could reduce annual HIV incidence in Swaziland by 75 percent by 2025. 29 The country's target is to deliver voluntary medical male circumcision (VMMC) to 80 percent of adult and infant males by 2015. 30 By 2012 it was evident that by circumcising 1 in 5 men, Swaziland was on the right track to reducing the chances of sexual HIV transmission.

Billboard promoting male circumcision in SwazilandDespite this progress amongst men, a greater focus upon preventing HIV among women is needed; as of 2011, women accounted for most new HIV infections, with around two out of three people newly infected being reported as female. Two crucial reasons why this may be are that one in three women experience sexual violence before the age of 18 showing how vulnerable young girls are in the country. 31 The common practice of polygamy also puts women at greater risk of becoming infected with HIV as this practice often involves multiple sexual partners. However the major route of transmission in 2011 remains through heterosexual contact among persons with one sexual partner. 32 Among the population aged 15 and older HIV prevalence is 15.3 percent among women, compared to 6.3 percent among men. 33

Condom distribution

The number of new annual infections in Swaziland could be seriously threatened if condoms are not used correctly and consistently, particularly considering that the Swazi tradition of polygamy still exists. By promoting consistent condom use and single-sexual partnerships, the government is trying to reduce this risk. 34 In particular focus are young people and the uniformed forces, due to the high HIV prevalence among these populations.

Condoms have been widely available in Swaziland since the 1990s in health facilities, community centres and key population hot-spots. However their use has been labelled controversial and unpopular in the past. 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. 35 However 2011 figures show condom use at last sexual intercourse now stands at 71.4 percent, showing that sexual health education is being heard. 36

Although the government has encouraged condom use, some influential community leaders have undermined the government's message. The first Swazi person to declare their HIV status was Hannie Dlamini, who once stated that "condoms don't stop AIDS" and only "faithfulness and abstinence stop AIDS". 37 Religious and traditional leaders have also described condoms as “unSwazi”.

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, Manzini 38

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

Behaviour change campaigns

Multiple partners, child marriages, polygamy and gender inequality continues throughout Swaziland. Such behaviours and traditions have been shown to heighten the spread of HIV and increase a person’s risk of HIV infection. 39 HIV disproportionately affects Swazi women, particularly young women; HIV prevalence among women aged 15-24 years was 15 percent in 2011, significantly higher than the 6 percent reported among men of the same age. 40

Child marriage and polygamy are major factors that result in early sexual debut; which can greatly increase a girl or young woman’s risk of becoming infected with HIV. Both polygamy and child marriage often results in young women marrying older men, who may be having unprotected sexual intercourse with a number of women, and with whom they may not be able to insist on condom use. The subordinate status of women, particularly of those in this situation, can also place them at an increased risk of sexual violence and less likely to have access to education and health information. 41 High unemployment can also contribute to inter-generational sexual relationships, for example, some young women may have sexual relationships with older men, from whom they may receive money or gifts. 42

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”. 43 The following year the UN reported that almost two in three female secondary school students listened to this advice and were abstaining from sex until their late teens. 44 This positive attitude towards delaying first sex was also reported in 2011; only 4 percent of women and 3 percent of men had sexual intercourse before the age of 15, down from 7 percent and 5 percent respectively in 2007. 45 This change in behaviour is reflected in the number of 15-24 year olds living with HIV – which has remained stable since 2007. Nevertheless, Swaziland must continue to expand its HIV prevention efforts, particularly amongst this group, so that young people have access to education and contraception when they do become sexually active.

Reducing the number of sexual partners people have, can reduce a person’s risk of infection. Multiple sexual partnerships, particularly if partners are concurrent and if condoms are not used consistently, can greatly increase the risk of exposure to HIV. In Swaziland, men are considerably more likely to have multiple partners; in 2011 less than 3 percent of women aged 15-49 reported having sex with more than one partner in the last 12 months, whereas amongst men it was 15 percent. 46

The success in mobilising greater positive behaviour change has been recognised by Swaziland’s government in 2012:

“Appropriate behavioural change is observed particularly among the youth whose HIV prevalence has reduced.” 47

HIV education poster in SwazilandGenerally King Mswati has also been praised for speaking out about HIV/AIDS, however, community organisations have said his sexual practices set a poor example. As of 2012, the King had 14 wives in accordance with the Swazi tradition of polygamy.

Reassuringly, the Swaziland government, who in September 2012 enforced the new Child Protection and Welfare Act that prohibits marriage to underage girls, has also acknowledged the risks associated with child marriage. As a result, men who enter into an underage marriage, and also parents who attempt to arrange a marriage for a daughter under 16, could face up to 20 years imprisonment and a fine. 48 It is hoped that this will increase the rights of young girls and help reduce the spread of HIV in this demographic category.

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. 49 Initial funding to implement PMTCT programmes was received from the Elizabeth Glaser Pediatric AIDS Foundation in 2004. 50 These programmes included training healthcare workers, scaling up voluntary testing and counselling services and supplying free nevirapine. By 2010, 88 percent of Swazi health facilities were providing HIV prevention and treatment services for pregnant women. 51 As of June 2012, the Foundation was supporting 113 sites that provide PMTCT services. 52

Between 2004 and 2010, the number of national sites providing PMTCT services increased from 44 to 154. 53 54 By 2012, around 81 percent of pregnant women were being tested for HIV per year and 83 percent of those testing positive received antiretrovirals to prevent the transmission of HIV to their baby. 55 Whilst remaining high, PMTCT testing and treatment coverage figures have declined since 2011. 56 57

Swaziland has further succeeded in delivering effective PMTCT services by completely phasing out the use of single-dose nevirapine in 2010. 58 Despite this, an estimated 15 percent of children born to HIV-positive mothers were infected with HIV in 2011, 59 indicating Swaziland must maintain its commitment to testing pregnant women and delivering treatment to those found to be living with HIV.

HIV and AIDS treatment in Swaziland

The government first launched its strategy to provide free nationwide antiretroviral treatment (ARVs) to all in 2003. 60 In 2012, Swaziland joined the relatively small number of low- and middle-income countries to have achieved universal access to treatment, meaning that at least 80 percent of the country’s population who need HIV treatment receive it. 61 The progress and success Swaziland was making towards universal access to treatment was acknowledged in 2009 when antiretroviral therapy had become available at 89 health facilities across the country and just over 47,000 people were receiving ARVs. 62 Furthermore, as Swaziland’s antiretroviral drugs are 100 percent domestically funded, their treatment programmes are less reliant on international donors and therefore more sustainable in the long-term. 63 Despite the notable improvements that have been made in making treatment more accessible, these gains have been felt far more by adults living with HIV. Access to treatment for children continues to be extremely inadequate, with only 54 percent of children eligible for treatment receiving it in 2012. 64

Swaziland has addressed many challenges en-route to achieving universal access. Some of the barriers that have impeded efforts to increase access to HIV treatment have included; people experiencing difficulty when trying to access treatment services, for example cost and distance, limited infrastructure, a lack of capacity in treatment clinics, as well as the continued tendency of people to visit traditional health practitioners, rather than certified health professionals. 65 Key changes addressing these barriers were implemented in 2011; the decentralisation of ART and PMTCT services to smaller clinics and the introduction of task-shifting. The construction of KaGogo Community Centres (traditional grassroot organisations) have aided decentralisation targets and vastly increased access to information for people in rural areas. Moreover, although slow to start, task-shifting programmes have now been implemented, allowing nurses to carry out routine prescription duties that would normally be carried out by doctors. 66 One of the main results that have come out of such changes, is that retention of patients 12 months after starting ARV treatment has rapidly increased from 77 percent in 2010 to 87 percent in 2011. 67

Another obstacle that has hindered 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. 68

In 2012, the Ministry of Health organised meetings across the country to enlist local chiefs into efforts to expand antiretroviral treatment. 69 Joel Sacelo, a respected local leader in the Shiselweni region, declared at a meeting of fellow traditional leaders:

“I know many of you will be surprised today to learn that I am HIV-positive, but it comes from my heart to disclose my status because I want the Swazis out there to know that taking ARV’s does not mean you are going to die…it has been two years since I began (taking ART).” - Joel Sacelo, aged 75, traditional leader and pastor 70

HIV funding

Latest available data regarding funding shows that international sources still cover the majority of Swaziland’s HIV response at 60 percent in 2010, up from 55 percent in 2009; domestic funding remains at around 44 percent. 71 This high level of internationally sourced funding suggests Swaziland’s HIV response is currently unsustainable and reliant on continued international investment in the global HIV response. Swaziland’s HIV response is financially supported most fully by the Global Fund and PEPFAR; and was hit particularly hard because of the cancellation in November 2011 of Round 11 Global Fund funding. 72

The cancellation of funding had the greatest impact upon most-at-risk groups such as sex workers, MSM and IDUs as it was the first time they had been considered in a proposal. Although the country's gains in PMTCT and treatment access offer hope to the HIV response, without a scale-up of prevention strategies for MARPs, it is likely that HIV infections will increase among these groups.

The future

Although progress has been made with regards to treatment and PMTCT; poverty, gender inequality and risky cultural practices continue to contribute to a high risk of HIV infection among the general population. 73 Effective prevention initiatives and a greater focus on improving access to HIV testing facilities, are also urgently needed.

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. 74 In 2007 the TB/HIV National Coordinating Committee (NCC) was set up with a focus on providing TB services at ART sites, but four years on in 2011, figures for treating co-infected individuals remain low at just 32 percent. 75

Swaziland's King has been previously 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!". 76 77 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". 78 These accounts indicate 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.

Despite these past criticisms, a 2012 report 79 praised the King, the Prime Minister and senior government officials for having good political presence against HIV and AIDS, as portrayed by their speeches and participation in HIV programme launches and campaigns. Moreover, certain bill amendments, such as to the Marriages Act of 1964 and the Employment Act of 1980, as well as the creation of the Sexual Offences and Domestic Violence bill of 2010, suggests that the Swazi Government have renewed their commitment to the HIV response.

Further Information

The history of AIDS in Swaziland

“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.” - 80

In the mid-1980s, Swaziland's government responded to the first cases of AIDS by setting up the Swaziland National AIDS Programme (SNAP). SNAP introduced a short-term strategy for 1986 to 1988, and later a medium-term strategy, which lasted from 1989 to 1992. Both these strategies aimed to provide information and HIV education,   promote condom use, manage the spread of sexually transmitted infections, and screen all donated blood. In order to monitor national strategies, antenatal HIV prevalence is often used as a representation of a country's progress. HIV surveillance was introduced in 1992, and by that time 3.9 percent of pregnant Swazi women were HIV-positive. 81

In 1993 the HIV/AIDS programme was restructured, and subsequently the national strategic plans of 1994-1997 and then 1998-2000 were developed. 82 It is unclear how much was achieved at this time, as by 1996 HIV prevalence among pregnant women had increased rapidly to 26.3 percent. 83

A new 1998 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. 84 In 1999 the King declared AIDS a national disaster 85 and 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. 86 This focused on improving health services; changing behaviour through mass media outlets, schools and workplaces; and minimising the future impact of the epidemic, especially for vulnerable groups such as orphans.

The government announced in the strategic plan that the year 2000 and beyond “will be the time of delivery” for HIV/AIDS policy in Swaziland. 87

In 2001, the National Emergency Response Council on HIV and AIDS (NERCHA) replaced the CMTC. NERCHA is responsible for mobilising an expanded response to the epidemic, in line with the most current National Strategic Framework 2009-2014. In 2005 the World Health Organization (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. 88 Figures for HIV prevalence among pregnant women support this statement, with a slight decline reported from 42.6 percent in 2004 to 39.2 percent in 2006. These rates then rose slightly between 2006-2008, 89 and leveled at 41 percent in 2010, showing signs of stabilisation. 90

During a 2010 visit, UNAIDS Executive Director Michel Sidibé, praised Swaziland’s achievements in addressing HIV and AIDS in the country, particularly the scale up of initiatives preventing mother-to-child transmission (PMTCT). However, he emphasised the need for Swaziland to scale up other HIV prevention efforts, if new HIV infections were to be avoided. He reiterated estimates that suggested 3 in every 100 people in Swaziland would be infected with HIV, every year, if HIV prevention efforts were not expanded. 91


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