HIV and AIDS continues to be an overwhelming crisis in Swaziland, rapidly spreading and impacting deeply on the social, cultural and economic spheres of life. The high HIV prevalence and its consequences put enormous pressure on an already stretched health care system. Over half of all hospital beds are occupied by patients with HIV and AIDS related illnesses leading to congestion in the hospital wards. The crude death rate has increased as a result of AIDS mortality, from 10 in 1990 to 21 deaths per 1,000 populations in 2007, a level usually seen in conflicts or natural emergencies.
WHO estimated that, in 2006, two thirds (64 percent) of all deaths in the country were due to AIDS. With increased uptake of ARV’s and improved survival of people living with HIV, it has been recommended that countries measure progress in the response by assessing trends in HIV incidence (the number or rate of new HIV infections occurring). Currently incidence rate is estimated at 2.8 percent per year, while prevalence in the reproductive age population (15-49) is 26 percent (Swaziland Demographic and Health Survey (SDHS) 2006/07).  According to the analysis from the Know Your epidemic and know Your response, it is estimated that 68% of new adult infections occur among individuals aged 25 year plus, with majority (62%) occurring among females and about 19% of all new infections occurring in children 0-14 years. It has been further established that transmission occurs mainly between those in long term “monogamous” stable relationships and those aged 25 and above.
There are however 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 been rising sharply from the 90’s from 4 percent in 1992 to 42 percent in 2008 (Figure 6).[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 14,667 new infections occurred in 2008 and is expected to stabilise at this level till 2015.[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, poor logistics and management systems for condoms, lack of employment, weak laws to protect women and girls, and sexual violence.  Weak governance, poverty and societal norms and values are some of the main root causes of high HIV prevalence and incidence in the country.
The level of HIV prevalence across the four regions depicts significant variations by residence, with 41 percent prevalence for urban and 37 percent for rural areas (SDHS),[3] (Figure 4).[4] While the pandemic is reaches to all population groups, women under 25-29 years (49%) and men 35-39 years (45%) are the hardest hit. More women (31 percent) than men (21 percent) are infected (Figure 5).[5] Women and girls are also disproportionately affected by the epidemic since they account for 98% of the caregivers.[6]
Treatment programme areas include 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), care and support by Traditional Health Practitioners (THPE enhanced availability of anti-retroviral therapy (ART) has brought longer and improved quality of life to many people living with HIV. By March, 2009, 60 percent of those in need received ART and it is projected that the country will attain universal access in this area by 2015.  In PMTCT, the successes are even more impressive with 81 percent coverage among HIV positive pregnant  women .[7] However, the high rates of tuberculosis (TB) among HIV positive people poses further challenges to treatment programmes and the burden of care, especially for community based and palliative care by far outweighs the resources currently available, compromising the delivery of comprehensive quality care and support to people living with HIV (PLHIV). Furthermore, due to the low level of HIV testing, a large proportion of the Swazi population, still do not know their HIV status and continue to spread the disease and/or become infected unknowingly.
The repercussions of HIV and AIDS have been particularly devastating for children in the country, placing them in an increased state of vulnerability. The number of children orphaned by AIDS in Swaziland was estimated at around 65,000 in 2007 and they are expected to increase to 76,000 by 2015.[8] Also among the under-fives, HIV and AIDS is now considered to be the number one cause of death. Scale-up of HIV prevention among young women of reproductive age will be critical in reducing children’s vulnerability to HIV infection. Furthermore, the strategy for the management of childhood illnesses is still inadequately integrated into child health programmes so the majority of children infected with HIV are not accessing treatment.

Current Policies and Strategies

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 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 based on the ‘three ones’ principle: one action framework, one national coordinating authority, and one monitoring and evaluation system. Under this principle, the NERCHA is mandated to coordinate and facilitate the national response to the pandemic.
The new National Multi-Sectoral Strategic Framework for HIV and AIDS 2009-2014 builds on the achievements and lessons learned from the review of the National Strategic Plan II (NSP II). Compared to its predecessor, the NSF it adopts an evidence-informed and results-based approach
The response has also developed a policy context which is conducive to HIV programming -  key policies on children (2003), HIV/AIDS (2006), blood safety (2006), and health (2008), as well as important acts (administration of estates, girls and women’s protection, marriage, maintenance, interstate succession), and guidelines (HBC, ART, HCT/VCT, PMTCT) all serve to strengthen the policy environment.  Other essential  additions will be the gender policy, the male circumcision policy, and the sexual offences and domestic violence bill (all at draft stage).  However, some legislation and related policies are not fully implemented – there are indications that laws are still very much “on paper”. Two reports (UNGASS 2008 and the WLSA study 2005) concurred on this.

 Outstanding 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.[9]  Among rural households, HIV and AIDS have led to a substantial decline in agricultural productivity, due to downshifting in crops and land cultivated (see Chapter 7). Perhaps this partly explains the extremely high levels of stunting in all the regions with the highest proportion of (43%) occurring among children aged 18-23 months and 10% of children under 5 being severely stunted[10]. OVC are disadvantaged compared to non OVC in terms of nutrition with 11% of OVC being underweight compared to 7% of non OVC[11].
The epidemic presents a unique challenge to the health sector because staff attrition is draining its workforce while demand for health care 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.[12] The high TB prevalence among people living with HIV, 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, 13,000 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.[13] It also projected that the cost of sickness 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

The population of reproductive age is most affected directly by HIV, resulting in a dramatic increase in the number of orphans and vulnerable children (OVC) in Swaziland since the mid-1990s. In 2007, there was an estimated 130,000 OVC (31 percent of all children),[14] and the number is expected to grow further. 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/or ailing grandmothers. However, given the scale of the problem and the decline in traditional safety nets, care givers are often severely strained and unable to provide and care for the growing pool of OVC.  This has led to a rising number of child headed households in the country.
Care and support provided to OVC has improved substantially in recent years, in large part through enhanced coordination under the National Plan of Action for OVC (2006-2010). There are 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, placing them at greater risk of HIV infection.[15] 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, knowledge and skills necessary to sustain livelihoods, thereby contributing to food insecurity and deepening poverty. While there is a paucity of data on the effects of HIV and AIDS on poverty, there is significant evidence suggesting that its effect at the household level 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 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, with HIV deepening poverty, and poverty, in turn, increasing vulnerability to HIV.

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 from all walks of life, thus stigma attached to the disease remains a major challenge. 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 about 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, therefore, 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 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.[16] The ability to negotiate safe sex is possibly the most indispensable asset for HIV prevention, but especially in marital unions, women’s status is compromised by societal expectations.[17] The 2007 ‘National Study on Violence against Children and Young Women in Swaziland’ [18]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 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.
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 and AIDS and Culture (2008)[19] 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 show that while there is high general awareness about HIV (over 90 percent), comprehensive knowledge about prevention of HIV transmission is low (only 52.1 percent for women and 52.3 percent for 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, consistent condom use and male circumcision have to be effectively brought up to scale. This requires improved coordination of the prevention response and increased financial support in the area of HIV prevention.
Some laws relevant to HIV prevention, for instance on rights in marriage, estate management and sexual abuse, are inadequately applied and enforced, and may clash with traditional laws There is scope to redress these shortfalls, through advocacy and sensitization programmes to build awareness and give “teeth” to legislation, as well as legal support programmes to ensure that vulnerable populations benefit from the rights enshrined in existing legislation. There is a sense amongst community members that leadership structures do not spend enough resources on HIV prevention, do not set a good example in their personal behaviour/ sexual practices, and do not do enough to oppose bad treatment of PLHIV. 

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