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
National Emergency Response Committee on HIV/AIDS (NERCHA)
and United Nations Programme on HIV/AIDS (UNAIDS)
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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
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
Why is HIV prevalence in Swaziland so high?
What can be done about it?
What are the innovative responses?
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
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
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.