Swaziland, a small landlocked country in southern Africa, has the highest HIV prevalence in the world, with 27% of their population living with HIV. In 2013, 11,000 people were newly infected with HIV and just over 4,500 people died of an AIDS-related illness.1
HIV and AIDS has had a devastating impact on Swaziland. According to 2013 estimates, life expectancy in the country is just 49 years – amongst the lowest in the world.2 However, over the last decade Swaziland have done well to curb the HIV epidemic in the country. They have one of the highest rates of antiretroviral treatment coverage in sub-Saharan Africa, and they have also increased their own investment and funding for the HIV response.1
Overall, HIV prevalence in Swaziland is stabilising. HIV incidence has decreased from 2.5% in 2011 to 1.8% in 2013 and the number of HIV-positive infants born to HIV-positive mothers also decreased from 12% to 3% between 2011 and 2012.3 Nevertheless, the huge amount of people living with HIV in Swaziland means that it is still the biggest public health concern for the country.
Key affected populations in Swaziland
Heterosexual sex is the main mode of HIV transmission in Swaziland – accounting for 94% of all new HIV infections.3 Low and inconsistent condom use, intergenerational sex, transactional sex, gender inequalities and gender-based violence, low uptake of male circumcision and multiple and concurrent sexual relationships have all been identified as key drivers of the HIV epidemic in Swaziland.3 However, certain groups are more affected than others.
Women and HIV in Swaziland
Women are disproportionately affected by the HIV epidemic in Swaziland. Of the 200,000 people living with HIV, 110,000 are woman.1 In the context of the entire population, 31% of all women are living with HIV, compared to just 20% of men.3
HIV incidence for women increases dramatically between the ages of 15-19 and 20-24. This sharp increase has been attributed to the high level of intergenerational sex between men and young, sexually inexperienced women. The rate of women aged 15-24 who had high risk sex with men who are 10 or more years older than them has doubled from 7% in 2006/7 to 14% in 2010.3
Polygamy and child marriage are commonplace in Swaziland. These cultural practices put woman in a subordinate role in society resulting in early sexual debut and difficulty negotiating condom use. All of these factors increase their risk of HIV.
Orphans and vulnerable children and HIV in Swaziland
There are an estimated 229,000 orphaned and vulnerable children (OVC) in Swaziland – this accounts for almost half of all people under 18.4 Latest estimates show that the prevalence of OVCs has increased from 31% to 45% from 2007 to 2010.4
The impact of so many AIDS-related deaths in Swaziland exacerbates existing poverty for families, resulting in a very youthful population. More than a third of the population are under 14 years old, and just under half are under 18.4 Only 6% and 5% females and males respectively are over 65.5 With such high HIV prevalence amongst the most productive working age ranges, responsibility for the care of OVC children often falls upon older generations, such as grandparents.
Men who have sex with men (MSM) and HIV in Swaziland
Estimates suggest that HIV prevalence among men who have sex with men (MSM) in Swaziland is 17%. Data about MSM in Swaziland is limited, and there are few programmes specifically targeting them.6 Sex between men is also illegal, and there has historically been little appetite by the government to address their needs or acknowledge that they exist.7
A study conducted by USAID found that 25% of MSM had reported having sex with female partners in the last year – meaning that the heightened risk of this group may get transferred to the general population.7 Knowledge about condom use and HIV was high, however only 18% knew of the heightened risk to HIV from anal sex, and only 21% had ever been reached with information on sex between men.
Stigma and self-stigma are also major issues. Almost two-thirds of MSM were scared to reach out to healthcare workers because of their sexual orientation.7 Only 33% of HIV-positive MSM in the USAID study were receiving treatment for HIV.7
Female sex workers and HIV in Swaziland
Swaziland has the highest HIV prevalence among sex workers in the world, with 70% of this group living with HIV.1 FSW have a high number of partners, with 33% stating that they have an average of six partners per week.
Condom use is high, but inconsistent among FSW in Swaziland. 83% reported using a condom at last sex with a regular partner, however only 69% had reported having sex without a condom in the last six months. Over 60% of female sex workers said that it would be hard to turn down more money for having sex without a condom due to economic hardship.6
HIV testing and counselling (HTC) in Swaziland
In recent years, the number of people testing for HIV, and receiving their results, has rapidly increased, from 16% in 2009, to an estimated 40% in 2011.3 Uptake of HIV testing and counselling has more than doubled since 2009, with an estimated 253,000 and 275,000 HIV tests performed in 2012 and 2013 respectively.3
Swaziland has made big steps to expanding access to HIV testing and counselling (HTC) in the country. At the end of 2003, they had just 13 sites providing voluntary counselling and testing (VCT).8 However, in 2006 a provider-initiated approach to HTC was mainstreamed, making HIV testing available at all health facilities. 83% of all health facilities now provide HIV testing, and over 60% of all HIV tests given were provided-initiated.4
Despite improvements, uptake of HTC is still relatively low and remains a significant problem for Swaziland. According to a 2010 government survey, only 40% of people aged 15-49 had tested for HIV in the year previous, and almost 40% had never tested for HIV and therefore do not know their HIV status. Stigma and self-stigma have been identified as key reasons behind the low uptake of HTC.4
Antiretroviral treatment (ART) in Swaziland
According to UNAIDS 2013 estimates, Swaziland has around 92,200 people on antiretroviral treatment, representing a treatment coverage of 49%.1
The Swaziland government first launched its strategy to provide free nationwide antiretroviral treatment to all in 2003. Before WHO changed their guidelines for treatment eligibility in 2013, Swaziland joined the relatively small number of low- and middle-income countries to have achieved universal access to treatment, meaning that at least 80% of the country’s population who need HIV treatment received it.9 Swaziland now have plans to implement the new 2013 treatment guidelines, initiating people on treatment earlier than before. They will also offer test and treat to all those who want it, but especially pregnant mothers, those people who are also living with TB or hepatitis, and children.
Swaziland’s treatment programme is 100% funded and procured by the government, without help from international donors.3
HIV prevention programmes in Swaziland
Prevention of mother-to-child transmission (PMTCT)
Between 1992 and 2010 alone, the HIV prevalence in pregnant woman increased from 4% to 41%.3 With this high prevalence, prevention of mother to child transmission (PMTCT) is seen as a vital entry point for accessing HIV services for the entire family.4
PMTCT programmes include counselling and testing for HIV; HIV prevention services for expectant and breastfeeding mothers; ART for mothers living with HIV and their infants; family planning and long-term referral for treatment.4 In 2013, 89% of all pregnant women tested for HIV, and 84% of HIV positive pregnant women received ART.3 The number of women transmitting HIV to their child has decreased from 10% in 2010, to 2.8% in 2012.3
The scale-up of PMTCT has involved expanding PMTCT implementation at all healthcare facilities and at the community level; innovative interventions to involve men; and strengthening the follow-up to antenatal care and engaging their new-born infants with care.3 In 2013, 162 healthcare facilities out of a total of 252 offered PMTCT services. In the ‘Extended National Multisectoral HIV and AIDS Framework’ there are also plans to roll out option B+ across the country, meaning all pregnant HIV-positive women would receive treatment for life.4
Voluntary medical male circumcision (VMMC)
Given Swaziland’s generalised HIV epidemic and high HIV prevalence, voluntary male medical circumcision (VMMC) was adopted as an HIV prevention strategy in 2008 at the community level.4 Swaziland concentrated efforts on young men aged 15-24, where HIV prevalence was lowest for males.4 Since 2007, the number of men being circumcised has more than doubled, from 7% in 2007 to 19% in 2010.3
Swaziland was the first country to implement a nation-wide VMMC programme with help from PEPFAR, called the ‘Accelerated Saturation Initiative’, or ‘Soka Uncobe.’ The one-year programme was an ambitious plan to circumcise 80% of men in the country.10 VMMC was integrated into most healthcare facilities across the country. Other fixed sites and mobile services were provided by NGOs and other community based organisations. Intensified advocacy and mass communication plans were conducted targeting young men – particularly during school holidays. There were also efforts to increase neonatal circumcision.10
The programme has since been integrated into the Swaziland ‘Extended National Multisectoral HIV and AIDS Framework’.4 Uptake of VCCM has been a challenge in Swaziland, with a low social acceptance of the procedure. Only about 32,000 men were circumcised through the programme – just 20% of the target demographic.10 Despite around 90% awareness of circumcision, reasons for low uptake include unwillingness because they would still have to wear a condom and fear of pain. A belief in witchcraft in Swaziland is also an issue – with many men believing that their foreskin may be used for “ulterior motives”.10
Condom availability, distribution and use was historically poor in Swaziland – and particularly in rural areas. In 2007, only 56% of women and 48% of males used condoms with every high risk sex.11
To overcome some of these issues, the Swaziland government developed a strategy to ensure the condom supply and distribution system was managed correctly, in addition to education and advocacy to increase their use.11 The Swaziland government also allocated a specific budget line for the procurement of condoms.4
As a result, condom use in high risk sexual contexts has increased from 56% in 2007 to 73% in 2010. Condom use is highest among young men aged 15-24 (85%) and women aged 25-39 (76%).3 Between 2008 and 2011, the supply of condoms increased from just 8 million to 12 million.4 Additionally, of the 224 health facilities that provided condoms, only four experienced stock-outs.
Tuberculosis (TB) and HIV co-infection in Swaziland
Swaziland has the highest tuberculosis (TB) incidence rate in the world – with an estimated one in every 100 people developing active TB each year.12 Swaziland has a dual epidemic of TB/HIV, with 80% of all people who have TB also co-infected with HIV.
To tackle the problem, Swaziland started a programme of strengthening and integrating TB/HIV services. These services have been decentralised, and are now offered in a ‘one-stop-shop’, where people can seek screening for TB and HIV testing, as well as being able to pick up their treatment for both at the same time. In 2012, over 90% of all TB patients were tested for HIV, and over 60% received treatment for both. From 2007 to 2012, the death rate from TB has decreased from 19% to 9%.3
Barriers to HIV prevention programmes in Swaziland
Stigma associated with HIV and AIDS in Swaziland prevents many people from being tested for HIV or declaring their HIV status. Swazi traditional opinion links HIV 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. There is evidence that this is changing slowly – with the recent increase in testing resulting in a decline in HIV-related stigma. The 2011 Stigma and Discrimination Index, found that although stigma has decreased, self-stigma among people living with HIV remains common.3
Swaziland is a highly patriarchal society with high levels of gender inequality. Men often dictate women’s reproductive and sexual health, with child marriage and polygamy common. Both of these cultural practices 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.3
The subordinate status of women, particularly of those in this situation, can also place them at an increased risk of sexual violence and low access to education and health information.14
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.15
Treatment access is often hampered by a pervasive belief in witchcraft and trust placed in traditional health practitioners, of which there are more than 8,000 in Swaziland.16 According to a 2008 government report, some people are tempted to replace antiretroviral drugs with medicines provided by these health practitioners, reducing levels of treatment adherence.16
Same sex relations and sex work are both illegal in Swaziland, with both groups reporting high levels of human rights violations against them. Around one-third of MSM and FSW report some form of legal discrimination.3 37% of FSW reported being refused police protection. 36% of MSM had been tortured due to their sexual orientation.3
The way forward
In recent years, Swaziland has made great progress in tackling HIV – particularly around the areas of treatment, PMTCT and reducing HIV incidence overall.
However, the high HIV prevalence among the general population means that the government will need to tackle many of the social and cultural problems that hamper the response. These include poverty, gender inequality and risky cultural practices that contribute to a high risk of HIV infection among the general population.3
Effective prevention initiatives and a greater focus on improving access to HIV testing facilities, are also urgently needed. As well as increasing the hold on the dual epidemics of TB and HIV.
The epidemic among key affected populations – particularly FSWs and MSM needs to be addressed. The government needs to work harder to collect data and understand the complex needs of these groups, so that adequate HIV programming can be developed.
- 1. a. b. c. d. e. UNAIDS (2014) 'The Gap Report'
- 2. UNDP (2014) ‘Human Development Report 2014’
- 3. a. b. c. d. e. f. g. h. i. j. k. l. m. n. o. p. q. r. s. t. Swaziland Ministry of Health (2014) ‘Swaziland Global AIDS Response Progress Report’
- 4. a. b. c. d. e. f. g. h. i. j. k. l. m. National Emergency Response Council on HIV and AIDS (2014) ‘The Extended National Multisectoral HIV and AIDS Framework’
- 5. UN Data (2014) ‘Swaziland’
- 6. a. b. USAID (2013) 'HIV Among Sex Workers and Men who have Sex with Men in Swaziland'
- 7. a. b. c. d. amFAR (2013) 'Achieving an AIDS-Free Generation for Gay Men and Other MSM in Southern Africa: Country Profile – Swaziland'
- 8. WHO/UNAIDS/UNICEF (2009) 'Towards universal access: Scaling up priority HIV/AIDS interventions in the health sector'
- 9. Government of the Kingdom of Swaziland (2010) 'Monitoring the declaration of commitment on HIV/AIDS (UNGASS) Swaziland country report'
- 10. a. b. c. d. PlusNews (2013) ‘Circumcision Plans go awry in Swaziland’
- 11. a. b. Swaziland Ministry of Health (2010) ‘2010-2015 National Condom Strategy’
- 12. World Health Organisation (WHO) (2014) ‘World Tuberculosis Report’
- 13. IRIN News (2012, 12 November) ‘Swaziland: HIV stigma still a barrier’
- 14. Plus News (2012, 20 September) ‘SWAZILAND: Child Marriages Banned’
- 15. PlusNews (2009, 3 December) 'Swaziland: Welile Mlilo, "The sugar daddies say they can give me what I want"'
- 16. a. b. The International Treatment Preparedness Coalition (2010) 'Rationing Funds, Risking Lives: World backtracks on HIV treatment'