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What is driving the HIV/AIDS epidemic in Swaziland and what can we do about it?

Final report prepared by Alan Whiteside, with Alison Hickey, Nkosinathi Ngcobo & Jane Tomlinson

for the National Emergency Response Committee on HIV/AIDS (NERCHA) and United Nations Programme on HIV/AIDS (UNAIDS)

April 2003

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Executive Summary

Swaziland is hard hit by the HIV/AIDS pandemic. Various forms of intervention strategies have been adopted by the government as well as civil society to combat the spread of the pandemic and deal with its consequences. However, little change in the trajectory of HIV prevalence has been observed thus far. This report reviews the documents on behaviour and the epidemic in Swaziland in an attempt to establish what is driving the epidemic. It asks ‘What is driving the HIV/AIDS epidemic in Swaziland? What more can we do about it?’ The questions posed were:

  • Why is HIV prevalence in Swaziland so high?

  • What can be done about it?

  • What are the innovative responses?
In the first part we look at the basic epidemiology and the data from Swaziland. Are the data – showing very high levels of HIV prevalence in Swaziland – correct? The surveys are excellent and we believe that they do indeed reflect the reality in Swaziland. The second question is ‘how unique is the national epidemic?’ Here the evidence is that, with the exception of Southern Mozambique the data show Swaziland to be on a par with other countries and provinces in the region. However what makes Swaziland unique is that prevalence rates seem to vary little between rural and urban areas and districts. Will it get worse? The evidence suggests that HIV prevalence rates may be reaching a plateau, but in all likelihood there will be a rise of a few more percentage points.

The second section looks at the drivers of the epidemic. Here we examine biologic and behavioural drivers then go on to look at socio-economic drivers. Swaziland’s population is youthful, which means that the epidemic will have an inbuilt momentum and prevention efforts will have to be maintained for the youth. There seems to be a high level of sexually transmitted infections and this will aid the spread of HIV. However there is a lack of information on this and it is an area for further research.

While the level of knowledge is generally good, people feel that they do not know enough, and there is confusion about some things. In addition material is needed in SiSwati. The most striking finding is that in-school youth have low levels of sexual activity (70% are not sexually active); the converse is true for out-of-school youth (more than 70% are sexually active). The lack of employment and recreational opportunities are also highlighted. While apparent levels of condom use are high, the report notes that condom promotion alone is not enough to stop the epidemic (it was certainly not in Uganda – the one success we have).

The social drivers include culture and women’s status. This was strongly emphasised at the workshop we held, but very little is written on the role of culture. We feel that this is a very sensitive area which requires involvement and empowerment by Swazi people. There are other factors of importance in Swaziland, including poverty, inequality and mobility. At the moment the economy is going through a very difficult stage and this will contribute to the spread of HIV. We note that it is times of transition that are most problematic. The report reviews the few recent studies of the impact of AIDS in Swaziland and notes the gaping hole – the lack of assessment of what AIDS means for the health sector. Finally it concludes by looking at drivers of Uganda’s success and implications of this for Swaziland.

Our conclusion is that the epidemic in Swaziland is very serious, but we know what is going on. There are some gaps in the research that need to be addressed but there is enough information available now to act. The workshop we held confirmed this. The biggest issues are around poverty and culture. The issue of culture needs to be addressed squarely but sensitively and by the Swazi people. There are signs of hope. The activities of National Emergency Response Committee on HIV/AIDS (NERCHA) and the participants at our workshop were evidence of a unique and exciting mobilisation. This is one of the things that will make a difference.

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