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HIV and AIDS in Swaziland

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HIV and AIDS statistics for Swaziland

Swaziland, a small landlocked country in southern Africa, has the highest HIV prevalence in the world, with 28.8% of their adult population living with HIV. In 2015, 11,000 people were newly infected with HIV and 3,800 people died of an AIDS-related illness.1

HIV and AIDS has had a devastating impact on Swaziland. According to 2015 estimates, life expectancy in the country is 57 years for men and 61 years for women.2 However, over the last decade Swaziland has done well to curb its HIV epidemic. At 67%, 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.3

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 .4 Nevertheless, the huge amount of people living with HIV in Swaziland means it is still the country’s biggest public health concern.  

Key affected populations in Swaziland

Heterosexual sex is the main mode of HIV transmission in Swaziland – accounting for 94% of all new HIV infections.5 Low and inconsistent condom use, intergenerational sex, transactional sex, gender inequalities, gender-based violence, multiple and concurrent sexual relationships and a low uptake of male circumcision are all key drivers of Swaziland’s HIV epidemic.6 However, certain groups are more affected than others.

Women and HIV in Swaziland

Women are disproportionately affected by Swaziland’s HIV epidemic. Of the 220,000 people living with HIV, 120,000 are women.7 In the context of the entire population, 31% of all women are living with HIV, compared to 20% of men.8

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 that occurs between older men and young, sexually inexperienced women. Around 14% of women aged 15-24 years had sex in the last 12 months with a partner who was 10 or more years older.9 The rate of women aged 15-24 who had high risk sex with men who are 10 or more years older than them doubled from 7% in 2006/7 to 14% in 2010.10

Around 12% of women aged 15-49 years are in a polygamous marriage. Females getting married at a younger age is also fairly common; 9% of women now aged 20-49 were married by the time they were 18, and 1.3% were married by the age of 15.11 Gender based violence and abuse is also commonplace. One in three women report experiencing some form of sexual abuse by the time they were 18, 79% of whom knew the perpetrator. These outcomes 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.

Swaziland’s Sexual Offences and Domestic Violence Bill has been passed by parliament for several years yet has still not been signed into law by King Mswati III. This lack of political commitment could be a result of deep social norms that view issues such as early marriage and gender equality as taboo.12

Orphans and vulnerable children (OVC) and HIV in Swaziland

In Swaziland, around 24% of children aged 0-17 years are orphans and 45% are either orphans or vulnerable.13 Around 47,000 of orphans will have lost their parents due to AIDS related illnesses.14

The impact of so many AIDS-related deaths in Swaziland exacerbates existing poverty for families, resulting in a very youthful population. Around 38% of the population are aged under 15 and only 5% are aged 60 or over.15 With such high HIV prevalence amongst the most productive working age ranges, responsibility for the care of orphans and vulnerable 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 (sometimes referred to as MSM) in Swaziland is 17.7%.16

Data about men who have sex with men in Swaziland is limited, and there are few programmes specifically targeting them.17 Sex between men is also illegal, and there has historically been little appetite by the government to address this group’s needs or acknowledge men who have sex with men exist.18 As a result, only 27% of men who have sex with men were reached with targeted HIV prevention programmes in 2013, the most recent data available.[pdf]19

A study conducted by USAID found that 25% of men who have sex with men also reported having sex with women in the last year – meaning there is a heightened risk HIV may get transferred to the general population.20 Although the study found knowledge about condom use and HIV to be high, only 18% knew of the heightened risk of 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. The study found almost two-thirds of men who have sex with men were scared to reach out to healthcare workers due to their sexual orientation.21

Female sex workers and HIV in Swaziland

Swaziland has the highest HIV prevalence among sex workers in the world. An estimated 70% are living with HIV.22

Data on female sex workers is limited. A 2014 study by the Johns Hopkins Centre for Global Health found 40% of female sex workers had an average of six partners per week.23

The study found condom use to be high but inconsistent. Around 83% reported using a condom they last time they had sex with a regular client. However, 69% also reported having sex without a condom in the past six months. Lower condom use was reported with non-paying partners than in commercial sex.24

Although a third of women reported anal sex in the last month, only a tenth were aware this was put them at heightened risk of HIV. Rape was common with nearly 40% reporting at least one rape and 17% reported being raped six or more times. More than a quarter (29%) reported having been to jail or prison, and slightly more than 5% reported injecting drug use in the past 12 months.25

HIV testing and counselling (HTC) in Swaziland

In recent years, the number of people testing for HIV has rapidly increased. In 2009, just 16% had tested for HIV and knew their results in the past 12 months. By 2014 this had risen to 66% of women and 54% of men.26

Swaziland has made big steps to expanding access to HIV testing and counselling (HTC) in the country. At the end of 2003, just 13 sites providing were voluntary counselling and testing (VCT) in the country.27 In 2006, Swaziland introduced a provider-initiated approach to HTC, this is when medical staff offer an HIV test rather than waiting for someone to ask for one. By 2014, 83% of all health facilities were providing HIV testing, and over 60% of all HIV tests given were provided-initiated.28 Community based testing is also increasing. In 2015, the government launched a self testing pilot scheme, enabling people to test for HIV at home.29

Antiretroviral treatment (ART) in Swaziland

In 2015, 74% of women and 56% of men living with HIV in Swaziland were receiving antiretroviral treatment (ART).30 The year before, Swaziland adopted World Health Organisation guidelines that anyone diagnosed with HIV should be started on ART regardless of their CD4 count (which indicates the level of HIV in the body). This means thousands more people are eligible for treatment than before.31

ART has been free in Swaziland since 2003.32 The country’s ART programme is entirely funded and procured by the government, without help from international donors.33

HIV prevention programmes in Swaziland

Prevention of mother-to-child transmission (PMTCT)

Between 1992 and 2010, HIV prevalence among pregnant woman increased from 4% to 41%.34 As a result, prevention of mother to child transmission (PMTCT) was scaled up and viewed as a vital entry point for accessing HIV services for the entire family.35

Some improvement has been seen, with HIV prevalence among this group standing at 37% in 2013.36 In 2015, UNAIDS reported that 95% of pregnant women living with HIV received antiretroviral treatment. In the same year, less than 500 children (aged 0-14 years) were newly infected with HIV, compared to 1600 in 2010.37 Around 78% of children (aged 0-14) living with HIV were receiving antiretroviral treatment.38

The scale-up of PMTCT has involved expanding PMTCT implementation in health facilities and at the community level. By 2013, 162 healthcare facilities out of a total of 252 offered PMTCT services.39 Other interventions include the better involvement of men in services, strengthening antenatal care follow-up and engaging new-born infants with care.40

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.41 Swaziland concentrated efforts on young men aged 15-24, where HIV prevalence was lowest for males.42

Circumcision rates have risen from 7% in 2007 to 25% in 2014 43 44 However, this is far below the country’s 2013 target to circumcise 80% of men.

Despite around 90% awareness of circumcision, and some increase in uptake, the need to still use a condom and a fear of pain have been given as reasons not to be circumcised. A belief in witchcraft in Swaziland is also an issue – with some men believing their foreskin may be used for ‘ulterior motives’.45

Condom promotion

In 2015, Swaziland had the second highest level of availability of male condoms in the region, with 51 condoms available per man per year. This is well above the United Nations Population Fund’s regional benchmark of 30 male condoms per man per year (2011–2014).46

According to 2014 data, the most recent available, 66% of women and 83% of men aged 15 to 49 years with multiple sexual partners in the last 12 months used a condom the last time they had sex. This shows a significant increase from 2007, when only 56% of women and 48% of males used condoms with every high risk sex.47

Safer sex practices were even higher among younger people with 70% of women and 93% of men aged 15-24 using a condom the last time they had sex with a non regular partner.48

Tuberculosis (TB) and HIV co-infection in Swaziland

An estimated one in every 100 people develops active tuberculosis (TB) in Swaziland each year. The country has a dual epidemic of TB and HIV, with 80% of all people who have TB also co-infected with HIV .49

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 73% received treatment for both. From 2007 to 2013, the death rate from TB has decreased from 19% to 9%.50

Graph showing numberr of TB patients liviing with HIV receiving ART in Swaziland, 2006-2013

Barriers to HIV prevention programmes in Swaziland

Social barriers

Stigma associated with HIV and AIDS in Swaziland prevents many people from being tested for HIV or declaring their HIV status. HIV is perceived to be linked with sexual promiscuity, and often causes HIV-positive people to be excluded from family activities.51

It is thought that stigma associated with HIV discourages people from testing. In 2012, the Ministry of Health conducted a national survey into HIV. It found 68% of women who tested HIV-positive were already aware of their status. However, around half (48%) of men who tested HIV-positive were not.52

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Graphic shpwing attitudes to HIV and people living with HIV in Swaziland

Those living with HIV 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 HIV testing linked to a decline in HIV-related stigma. Despite this, a 2014 survey by Swaziland’s Central Statistical Office found 37% of women and 36% of men displaying discriminatory attitudes towards people living with HIV.53 The 2011 Stigma and Discrimination Index found self-stigma among people living with HIV remains high.54

Cultural barriers

Swaziland is a patriarchal society with high levels of gender inequality. Men often dictate women’s reproductive and sexual health, and child marriage and polygamy are practised.  55 The subordinate status of women can also place them at an increased risk of sexual violence and low access to education and health information.56

Inter-generational relationships are common. High unemployment is a factor in this as some young women may have sexual relationships with older men (often called ‘sugar daddies’), from whom they may receive money or gifts. This is sometimes referred to as transactional sex. The age and gender imbalance in these situations can make condom negotiation difficult.57

Access to HIV services and treatment can be hampered by the existence of traditional health practitioners (THPs), who many people in Swaziland visit. However, many organisations, including the World Health Organisation, argue that THPs should be better recognised as primary healthcare providers so that they can become more closely involved in the delivery of effective HIV services.58

Legal barriers

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 men who have sex with men and female sex workers report some form of legal discrimination.59 More than a third (37%) of female sex workers report being refused police protection. A third (36%) of men who have sex with men report being tortured due to their sexuality.60

The future of HIV and AIDS in Swaziland

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 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.61

Effective prevention initiatives and a greater focus on improving access to HIV testing facilities are also urgently needed. The epidemic among key affected populations – particularly female sex workers and men who have sex with men – 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. The dual epidemic of TB and HIV remains a cause for concern.

Last full review: 
22 December 2016
Next full review: 
22 December 2019

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Last updated:
05 June 2017
Last full review:
22 December 2016
Next full review:
22 December 2019