Fighting HIV&AIDS Stigma and Discrimination - Goal 6
Overview

HIV and AIDS continues to be an overwhelming crisis, rapidly spreading and impacting deeply on the social, cultural and economic aspects of the Swazi nation. The rising prevalence of the HIV and AIDS infection rates and its consequences are putting enormous pressure on an already stretched health care system in Swaziland. Over half of all hospital beds are taken by HIV and AIDS related illnesses, rendering non-HIV/AIDS patients’ limited access to health care. The crude death rate had increased as a result of AIDS mortality, from 9.9 to 22.7 deaths per 1000 people in 2005.

There are signs that the epidemic is stabilizing, albeit at an unacceptably high level. Data from the Sentinel Surveillance show that the HIV prevalence among pregnant women attending antenatal care has increased from 4 percent in 1992 to 42.6 percent in 2004, stabilizing at 42 percent in 2008.[1] However, unlike in other countries in the Southern African region with high prevalence, the national response has yet to generate an actual reversal in epidemiological trends. It is estimated that approximately 16,200 new infections occurred in 2008 and this is expected to rise to just under 18,000 new infections in 2012.[2] The main drivers of the epidemic in Swaziland are multiple concurrent partnerships, early sexual debut, low levels of condom use, inter-generational sex, mobility and migration, low levels of male circumcision, and alcohol and drug abuse. This is compounded by underlying factors of gender inequalities and sexual violence.

The prevalence rate among antenatal clients as measured by the sentinel surveillance has continued to increase from 34.2 percent in 2000 to 39.2 percent in 2006. Sentimental surveillance data trends show that the epidemic is beginning to stabilize, as the prevalence rate dropped from 42.6 percent in 2004 to 39, 2 percent in 2006, which makes Swaziland the country with the highest disease prevalence in the world.

Regional variations show that the epidemic has been increasing since 2000 and has stabilized between 2004 and 2006. It is noteworthy though that Shiselweni region has recorded dramatic increases of 41.5 percent in 2006. Although, the prevalence is generally high in all the four regions of the country, Manzini region recorded the highest decline from 45.1 percent in 2004 to 38.6 percent in 2006. The level of HIV prevalence depicts insignificant variations between urban and rural areas as they were 35.6 percent and 32.7 percent for urban and rural areas in 2000, 44.5 percent and 40.3 percent in 2004, declining to 41 percent and 37 percent in 2006.

While the hyper-epidemic is generalised to all population groups, women and young adults are the hardest hit: More women (31 percent than men (21 percent) of men are infected. The highest prevalence is found among women aged 25-29 and men aged 35-39, with 49 percent and 45 percent, respectively.[3] The HIV epidemic has lead to an overall rise in mortality, with the estimated crude death rate rising from 10 in 1990 to 21 deaths per 1,000 population in recent years, a level usually seen in conflicts or natural emergencies. WHO estimated that, in 2006, two thirds (64 percent) of all deaths in the country was due to AIDS.

On the treatment front, enhanced availability of anti-retroviral therapy (ART) has brought improved quality of life and longer life to many people living with HIV and AIDS. In 2008, more than 30,000 people received ART, compared to 13,000 in 2005 (SAM 2008, NSF). However, the low level of HIV testing and high prevalence of tuberculosis pose further challenges. Despite very high HIV awareness, a large proportion of the Swazi population remains in the dark about their status and continues to die silently from the disease. 
The number of children orphaned by AIDS in Swaziland was estimated at around 70, 000 in 2006. Of the estimated 220 000 people living with HIV/AIDS in the country, it is estimated that approximately 15, 000 children of ages 0 – 14 years are living with HIV AIDS. Of these 1 600 have enrolled for Anti-retroviral treatment.  Also, while among the under-fives, HIV and AIDS is now considered to be the number one killer. 

The HIV and AIDS epidemic has placed children under an increased state of vulnerability. Paediatric HIV care and treatment is still limited in the country as it fall short of the 15% of the overall anti-retroviral treatment programme. Prevention of Mother to Child services uptake is still low as approximately 66% of pregnant women are enrolled for the programme. These services are still not adequately decentralized to rural areas. Further, the integrated management of childhood illnesses strategy is still inadequately integrated in child health programme.

Current Policies

Swaziland’s national response to HIV and AIDS is drawn from the National Multi-sectoral HIV and AIDS Policy, introduced in 2006. The goal of the National Multi-sectoral HIV and AIDS Policy is to “create an enabling environment for the national response to the HIV and AIDS epidemic.” The policy aims to provide a comprehensive and multi-sectoral framework for the national HIV AND AIDS response. It is based on the ‘three ones’ principle: one action framework, one national coordinating authority, and one monitoring and evaluation system. Under this principle, the National Emergency Response Council on HIV and AIDS (NERCHA) is mandated to coordinate and facilitate the national response to the pandemic.

Current Strategies

The new National Multi-sectoral Strategic Framework for HIV and AIDS (NSF) covering the 2009-2014 period builds on the achievements and lessons learned from the review of the National Strategic Plan II (NSP II). The NSF comprises four main areas, namely prevention; treatment, care and support; impact mitigation and; response management. Compared to its predecessor, the NSF is more advanced in terms of its evidence informed and results based approach The NSF also has a more strategic focus prioritizing several key strategic areas and a fewer outcome indicators within each component. The NSF is operationalized by the National Action Plan at the national level and the Regional Action Plan at the regional and sub-regional levels, moving the response towards a decentralized direction.

Developmental Challenges

Adverse Impact of HIV and AIDS on Productivity and Human Resources

There are significant economic costs associated with HIV and AIDS, particularly in terms of lost productivity as measured by staff absenteeism and attrition. An investment climate assessment survey by the World Bank revealed high levels of absenteeism among Swazi workers: one in four had been absent due to illness or illness of a family member during a one month period.[4]  Among rural households, HIV and AIDS have led to a substantial decline in agricultural productivity, due to downshifting in crops and land cultivated (see 2.6.4.3 below).

The epidemic presents a unique challenge to the health sector because staff attrition is draining its workforce while demand is increased. According to a study conducted in 2005, the annual attrition rate among health care workers is 7.9 percent, which translates to an estimated gap of over 1,000 staff by 2015.[5] The high TB prevalence, together with low treatment completion and emergence of resistant strains pose a threat to the health sector work force and have a potential to turn the HIV epidemic into a wider public health emergency.

Available data suggests that the impact of the epidemic on the education sector is also considerable. An HIV and AIDS impact assessment conducted by the Ministry of Education in 1999 projected that, as a consequence of HIV and AIDS, 130,000 teachers instead of 5,093 teachers would need to be trained to maintain the 1997 education level, which would require additional training cost of E400 million or more.[6] It also projected that the cost of sick and death benefits associated with teacher morbidity and mortality would reach E1 billion by 2016 for teachers only and E1.7 billion for both teachers and other staff in the education sector. All in all, available evidence points to a large magnitude of human resources lost to HIV and AIDS. The International Labour Organisation (ILO) projects that, by 2016, as much as 8 percent of Swaziland’s GDP would be devoted to training workers to replace those who have died from AIDS.

Increasing Number of Orphans and Vulnerable Children due to AIDS

HIV and AIDS primarily affects the reproductive age population, and as a result, the number of orphans and vulnerable children (OVC) in Swaziland has grown dramatically since the mid-1990s. In 2006/07, there was an estimated 130,000 OVC (31 percent of all children),[7] and the number is expected to grow further to 200,000 by 2010 (Government projected in 2004). As in other countries in Africa affected by the epidemic, the majority of OVC are taken in and cared for by their extended families. A vulnerability assessment conducted in 2006 found that 43 percent of Swazi households are hosting orphans. The burden of care for OVC is borne primarily by women, and often by aging and often ailing grandmothers. However, given the scale of the problem and decline in traditional safety nets, care givers are often severely strained and unable to provide and care for the growing pool of OVC, which led to a number of child headed households in the country.

Care and support provided to OVC has improved substantially in recent years, in a large part through enhanced coordination under the National Plan of Action for OVC (2006-2010). There are also an increasing number of national and community-based initiatives such as the OVC Education Grant, Lihlombe Lekukhalela (Shoulders to Cry On), Neighbourhood Care Points (NCPs) and kaGogo (Grandmother) Centres that largely build around traditional support structures in the communities. After the expansion of the OVC Education Grant, the school attendance of OVC is now at a par with that of non-OVC. However, OVC are still more likely than non-OVC to lack basic material support, such as food and clothing, and female OVC more likely than non-OVC to be exposed to sexual abuse and early sexual debut, which put them at greater risk for HIV.[8]. The high dependence on volunteerism in the care and support of OVC is also a concern for its long term sustainability.

Effects of HIV and AIDS on poverty deepening

HIV and AIDS threaten economic and agricultural livelihoods through the loss of breadwinners and knowledge and skills necessary to sustain livelihoods, thereby contributing to food insecurity and deepening poverty. While there is paucity of data on the effects of HIV and AIDS on income poverty, there is large evidence suggesting that the household level effect of HIV and AIDS on the livelihoods may be quite substantial. A 2002 study by Ministry of Agriculture and Cooperatives showed that households affected by AIDS-related death in Swaziland had experienced a 55 percent reduction in the production of maize, 34 percent in the area of land cultivated, and 30 percent reduction in herd size. The effect of HIV and AIDS is further exacerbated by recurrent drought and erratic weather conditions, which further reduces household income and worsens food insecurity. Increased expenditure on health care and funerals, as well as reduced income cause a further decline in personal savings and a reduction in agricultural investments. As a result, in the absence of comprehensive social protection systems, many households are forced to adopt survival strategies that have long-term consequences such as skipping meals, sales of livestock and, in some cases, taking children out of school. Finally, HIV and poverty form a vicious circle, while HIV deepens poverty, poverty, in turn, increases vulnerability to HIV through forcing women and girls to transactional sex.

Challenges of Fighting Stigma due to HIV and AIDS

Although there is general understanding that the HIV and AIDS epidemic has reached a generalized phase affecting individuals form all walks of life, there is still significant level of stigma attached to the disease. The SDHS found a low level of acceptance towards people living with HIV, especially among the uneducated population, which calls for increased efforts to build knowledge on HIV in all population groups. Currently, stigma presents a major barrier to HIV and AIDS prevention, treatment, care and support, discouraging people, and in particular men, from finding out their status and seeking the needed care. According to the SDHS, 81 percent of males aged 15-49 and 59 percent of females 15-49 have never tested for HIV. Even among people who have taken the first step of finding out their status, stigma in health care and community continues to be a barrier to HIV and AIDS care and treatment, particularly to adherence to ART and disclosure of status to partners. Reducing HIV and AIDS-related stigma, therefore, is critical in preventing further transmissions of HIV.

Societal and Cultural Challenges and Opportunities in addressing the Epidemic

It is widely agreed that cultural norms and values supporting male dominance in the area of sexuality and reproduction is a major contributor to the HIV epidemic, both globally and in Swaziland. In the Swazi culture, deep-rooted values and norms support unequal power relations between men and women, and gender discriminatory beliefs are upheld by many men and women, resulting in increased vulnerability of women to HIV (NSF). The ability to negotiate safe sex is maybe the most indispensable asset for HIV prevention, but especially in marital unions, women’s status is compromised by societal expectations (SDHS). The 2007 ‘National Study on Violence against Children and Young Women in Swaziland’ further shows that sexual violence against women is highly prevalent in Swaziland, with approximately  half (48 percent) of females reporting that they had experienced some form of sexual violence in their lifetime, with boyfriends and husbands as the most frequent perpetrators. More than half of the cases were not revealed to anyone, pointing towards tacit tolerance of gender-based violence in society.

The cultural practice of having multiple, long-term concurrent partnerships is perceived to be unacceptable, yet it is tacitly acknowledged and tolerated in the Swazi society. Evidence shows that due to the high infectivity in the early stages of the HIV infection (window period), HIV spreads much faster in networks of concurrent partnerships than in serial monogamy, which can result into a ten times greater epidemic. Swaziland is on a promising track in evidence-based prevention programming in this area.

Specific cultural practices often cited as contributing to the spread of HIV include bunganwa (having multiple female partners), sitsembu (polygamy), kushenda (having extramarital relationships), kungena (levirate or wife inheritance), kujuma (occasional short-term or overnight visits between unmarried lovers), among others. The Human Development Report on HIV&AIDS and Culture (2008) points out a few important aspects on culture and HIV prevention: (a) current practices are usually not how they were traditionally practiced, and (b) there are practices that could slow HIV transmission such as lusekwane and umhlanga (customs preserving chastity in boys and girls, for example through promoting non-penetrative sex) and umcwasho (a cultural rite to promote abstinence of virgin girls) (c) in terms of HIV risk, polygamy is no different from other forms of concurrent partnerships. However, more quality research is needed to determine both positive and negative contributions of cultural practices for the HIV epidemic in Swaziland.

Challenges in HIV and AIDS response strategies

While a great deal has been achieved in the last ten years in the area of HIV and AIDS, several key challenges remain, in particular in the area of HIV prevention. The SDHS findings shows that while there is high general awareness about HIV (90 percent), the awareness has not translated into concomitant behaviour, as evidenced by the relatively low comprehensive knowledge about prevention of the sexual transmission of HIV (52.1 percent for women and 52.3 percent men). The joint review of the NSP II noted that a key challenge with prevention interventions was the failure to reach targeted individuals or key populations with the level of coverage and intensity required to make a significant impact. Evidence-based interventions such as prevention-of-mother-to-child transmission, and behaviour change interventions to support abstinence, faithfulness and consistent condom use have to be effectively brought up to scale. This requires improved coordination of the prevention response and a reversal of the trend of declining expenditure on HIV prevention over the years[9].

There is a great deal of lessons to be learned from new research and experiences of other HIV affected countries. Based on the new evidence, Swaziland has adopted an ambitious plan for male circumcision as part of an integrated prevention package. There are also new studies suggesting the prevention benefits of earlier start of ART through its effect on lowering infectiousness: A recent study in the Lancet used a mathematical model to show that massive scaling up of universal voluntary HIV testing followed by immediate initiation of ARV could substantially reduce HIV incidence and mortality, possibility eliminating the epidemic within ten years.[10] The capacity of the health sector to provide comprehensive treatment, care and support continues to be a major challenge and will remain so in the future, especially in the light of the high TB prevalence.

Potential Areas of Cooperation

The national response to the challenges brought about by HIV and AIDS is perhaps the most organised one especially in the context of the UN-wide effort, particularly through the Joint UN Programme of Support (JUNPS). The JUNPS has been developed to strengthen the UN System’s contribution and to improve its alignment with the national response to HIV and AIDS. In this respect, the JUNPS is the operational plan for the UNDAF pillar on HIV, and it is as such an important step towards operationalising joint UN work on HIV. The JUNPS is fully aligned with the NSF and it represents the totality of the UN support to the NSF. The national overarching result of the NSF is to see the Swaziland HDI improve from 0.5 in 2008 to 0.55 in 2014.[11]

Taking into account the current situation, including the outstanding challenges discussed above, the following offer opportunities for cooperation in the area of HIV and AIDS between the Government of Swaziland and many of its stakeholders, including the UN System.

1.      Support to Improved Coordination according to the Three Ones Principle: The Three Ones principle, adopted by UNAIDS in 2003, emphasised the need for a one national coordinating authority, one national HIV and AIDS strategic framework, and one monitoring and evaluation system. In this respect, Swaziland established in 2003 the National Emergency Response Council on HIV and AIDS (NERCHA) whose mandate is to strengthen political will, clarify roles and responsibilities, clarify the mandates and functions of umbrella bodies, and steer the implementation of the national response to HIV and AIDS. Decentralised coordinating structures have also been established at regional and sub regional levels. However, support is needed to strengthen these structures in the following areas:

(a)    To make decisions and manage resources according to national guidelines.

(b)   Undertake planning that is aligned to the strategic plan and M&E. The roles and responsibilities of various stakeholders regarding joint planning also need to be clearly defined.

(c)    The regional coordination structures need to be strengthened to effectively coordinate regional plans, while NERCHA needs to clearly reposition itself to provide strategic leadership of the response.

(d)   Swaziland also has developed one national HIV and AIDS strategic framework, the NSF and set up a national M&E system which is linked to other sector systems. The country has also put in place a Technical Working Group for management and coordination of M&E initiatives and is guided by the national M&E framework for HIV and AIDS. All these structures require capacity enhancement to enable them better build systems for routine data collection and, evaluations and research.

2.      Addressing the Number of Orphans and Vulnerable Children due to AIDS: Support a Study to determine the full extent, real and potential, of the rising number of orphans and recommend the best way forward in addressing the national challenge, focusing on addressing the burden of care by both Government and non-state actors (including the traditional structures).

3.      Support to the Fight against Stigma due to HIV and AIDS: Support advocacy and other mass communication strategies that aim to make the Swazi society accept the realities of HIV and AIDS in a manner that reduces the stigma associated with the pandemic and the resultant marginalisation of those infected.

4.      Support Behavioural Change in the Face of the HIV and AIDS Pandemic: Support the national drive for increased awareness of the dangers (and associated challenges) of HIV and AIDS. Complementary to this should be support to massive scaling up of universal voluntary HIV testing followed by immediate initiation of ARV. The utilisation of a household or community-based approach is needed to mitigate the impact of HIV and AIDS, which should include rehabilitation and strengthening of livelihoods involving civil society organizations (CSOs) and community-based organizations (CBO). In the area of treatment, UN support is urgently needed at the level of care and support, focusing on the enhancement of the capacity of the health sector to address the HIV and AIDS challenge, which should include the attendant threat from rising TB prevalence.

5.      Strengthening Research and National M&E System: A strong national sector-based monitoring and evaluation framework is needed to track the progress made in the national fight against HIV and AIDS, utilizing data gathered through surveys and or research and data collected as part of routine monitoring activities. There is also a need for resource mobilization and adequate allocation of resources for monitoring and evaluation, especially in the health sector. An effective structure for identification of priorities for operational research is required. In the light of this, support is required towards strengthening the national M&E system for HIV and AIDS, focusing on routine data collection and analysis as well as evaluations and research.

6.      Support towards Treatment, Care and Support of PLHIV: UN support for Treatment, Care and Support of PLHIV should remain one of the major interventions in Swaziland given the prevalence levels of HIV and AIDS and the NSF priorities. The main focus of UN intervention at this level should be HTC, pre-ART and opportunistic infections; ART (including paediatric ART); Management of TB/HIV co-infection; provision of community-based care services (including palliative care); and care and support by Traditional Health Practitioners.

7.      Support Impact Mitigation: There is a need to establish and strengthen programmes geared towards minimizing the socio-economic impact of HIV and AIDS. The impacts includes the prevalence of orphans, a humanitarian crisis as a result of vulnerability due to poverty and intermittent droughts and floods, increased morbidity associated with HIV/ AIDS, inability of the health system to effectively respond to the burden of disease, reduced human capacity to implement the national response to HIV/AIDS. Already the economic gains realized in the past decades are beginning to be eroded as life expectancy and other quality of life indicators decline. With such challenges, it is difficult to reach some of the MDG goals.  In the light of this, there is need to support the adaptation of an enhanced household and community-based approach for coping with the burden of HIV by vulnerable households (mainly PLHIV, OVC and the elderly). This should entail the expansion of the scope and mandate of community-based systems and structures.

8.      Support for Comprehensive and Holistic HIV and AIDS Care Services: There is need to support the strengthening of health systems to deliver comprehensive and holistic HIV care services through novel approaches such as task shifting and strengthened linkages and referral systems.

9.      Effective Behaviour Change Communications Programmes: Whilst the national response to HIV and IDS has scaled up significantly, behaviour change towards risky behaviours in the population remains a challenge. As studies indicate slight decline in the number of new infections among young women, there is a great need to strengthen and expand prevention, especially behaviour change activities focusing on the youth. Implementation of behaviour change communication strategies has not made significant positive impacts as yet and support is required at this level.

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