Bent But Not Broken: The HIV/AIDS Epidemic in Swaziland

Avery C. Milne
Anthropology 349
March 25, 2015
Word count: 2869

Abstract:
Swaziland is a small country in Sub-Saharan Africa that currently has the highest rate of
HIV prevalence in the world at 27.4% (1). HIV first appeared in the country in 1987, and its
initial outbreak is thought to be linked to Swazi men who temporarily left to work in the South
African mining industry (2). There are a variety of cultural factors that play a role in its
transmission such as polygyny, wife inheritance, and gender inequality and violence (3). Stigma
may also deter Swazis from being tested (1). Knowledge of causality and transmission has been
shown to be good, especially in younger generations (4). Swazis may seek out a combination of
traditional treatments done by healers and more Western treatment provided by doctors, and in
past years, these two professions have collaborated to address the disease (5). Since 2003,
Swaziland has offered free anti-retroviral therapy (ART) to all patients with a CD4 count of less
than 350, and is making great progress to address the HIV/AIDS epidemic. Incidence rates have
lowered and Swaziland has achieved the significant benchmark of getting over 80% of eligible
individuals on ART (6). At the current rate of decreased incidence, and shifting of social norms,
it is predicted that HIV/AIDS morbidity and mortality will continue to lessen in Swaziland (4).

Human Immunodeficiency Virus (HIV), which leads to Acquired Immunodeficiency

Syndrome (AIDS) has a significant impact around the world, with an estimated 35 million
people living with HIV worldwide at the end of 2013 (7). HIV is a virus that attacks the immune
system, making those infected more vulnerable to opportunistic infections, resulting in a
diagnosis of AIDS when the immune system has been suppressed to a certain level (8). HIV is
estimated to have resulted in approximately 39 million deaths since its onset. However, when
treated with anti-retroviral therapy (ART), HIV can be managed as a chronic condition, and
individuals can live for many years (8). No country has felt the effects of HIV/AIDS as greatly
as Swaziland, which has the highest prevalence in the world and where one in four adults is
living with HIV (1). This paper will explore the epidemiology of HIV/AIDS in Swaziland, the
role of cultural factors, HIV causality, treatment, and the future of the HIV/AIDS epidemic in
Swaziland. For the purposes of this paper, the population of Swaziland in its entirety will be
considered as one ethnic group and will be analyzed in this sense. This is because the Kingdom
of Swaziland is virtually homogenous as most of the population belongs to the same tribe, so the
majority of the population share a common culture, language, history, and beliefs (9).
It is predicted that HIV/AIDS prevalence began to increase rapidly in Swaziland linked
to an increase of migrant workers who left to work on South African mines and later returned to
Swaziland. The increase of HIV in Swaziland in the 1990s is linked to the increase in migrant
workers from Swaziland to South African mines (2). HIV first showed up in South African
mines in the late 1980s, and the first case of HIV reported in Swaziland was in 1987. When HIV
first appeared in the mines, the prevalence among miner populations was approximately 1%,
however, this began to increase significantly, and reached a prevalence of 25% in 1990 (2). At
the same time, the number of mine-working migrants from Swaziland doubled from 1975 to

1990. The dominant hypothesis here is that individuals left their homes in Swaziland to work on
the mines where HIV was highly prevalent, engaged in high-risk behaviour, and then returned
home to their wives, bringing the virus with them.
The current prevalence rate of adults aged 15 to 49 is 27.4%, based on 2013 data
collected by UNAIDS, making Swaziland the highest in the world (10). Women have a greater
burden of morbidity, with a prevalence of approximately 31% to mens 20% for this age group
(11). Interestingly, the most significant age burden of those affected appears to have shifted: in
2007, men aged 30 to 34 and women aged 25 to 29 experienced the highest morbidity, but in
2011, the data showed a peak for women aged 30 to 34 and men aged 35 to 39 (11). HIV/AIDS
has a significant impact on children as well. There are also 17 000 Swazi children living with
HIV, and 73 000 children are orphans due to AIDS (10). Looking at prevalence seems to paint a
bleak picture; however, when considering incidence rates it is easier to understand the trends.
HIV incidence is decreasing in Swaziland: from 2.45% in 2011 to 1.79% in 2013 (11). Incidence
rates are highest in women aged 20 to 24 at 4.2% and men 30 to 34 at 3.12%. Heterosexual sex
is estimated to account for 94% of new infections, making it the most common route of
transmission (11). Life expectancy in Swaziland is 48.9 years, one of the lowest in the world (1).
The major risk factors in Swaziland identified by UNAIDS in their 2014 Global Progress Report
are: multiple sexual partners, transactional and intergenerational sex, gender inequalities and
violence, inconsistent condom use, and low rates of male circumcision (11).
There are a variety of cultural factors in Swaziland that contribute to the spread of HIV
in the population. Firstly, Swaziland is a strongly patriarchal and male-dominated society.
Decision-making tends to be the right of the man (3). Practices such as polygyny (one male
having multiple wives) and widow inheritance (kugena, the practice of a woman marrying her

late husbands brother) also contribute to the spread of HIV/AIDS (3). Kugena increases the
spread of HIV because often the husband who dies will have died from the virus, and the wife
will often be HIV positive as well, and when she marries and engages in sex the uncle, she will
spread HIV to him. The king of Swaziland, King Mswati, has 14 wives, showing that these
practices extend to all classes of society (1). Further, the familial duty to bear children and
contribute to population growth is strongly entrenched in societal beliefs, and has resulted
historically in a low rate of condom use (3). Religious and cultural leaders have referred to
condoms as unSwazi in the past (1). Women report to having multiple children, against their
will, because their husband makes the family-planning decisions (3). Another cultural factor at
play is child gender preference: as only a male can be an heir, there is a lot of emphasis on
having a son over having a daughter, so there may be continued attempts at children in order to
ensure that they have a son (3).
Child marriages are another cultural factor which facilitate the spread of HIV/AIDS,
resulting in a young sexual debut for girls (1). The average age for sexual debut is 17 for girls
and 19 for boys (11). These young girls tend to marry older men who have multiple partners,
and due to their subordinate status to men culturally, it is very hard for them to negotiate
condom use. This may be seen as disrespectful to the man, or may seem like they are
questioning his fidelity (2). This subordinate status of young women in Swaziland also puts
them at a higher risk for violence and less likely to be able to access education and health
information (1). Around one third of adults believe that violence against women is justified in
certain situations, and one in three women experience sexual violence before the age of 18 (1).
A low employment rate among young women also leads to transactional sex, where young
women may exchange sex for money and gifts with older men (1). Due to all of these factors,

HIV in Swaziland disproportionately affects young women (of those 15-24 years, 15% had HIV
in 2011) compared to their male counterparts (6% of those 15-24 had HIV in 2011) (1). Younger
men, therefore, could be considered to have more protection from these factors that facilitate
HIV transmission as compared to their female counterparts.
Moreover, stigma is a large issue facing those living with HIV. Many people are afraid to
be tested because the traditional line of thinking in Swaziland is that people who are infected
with HIV are promiscuous (1). People fear being outed and facing social exclusion and
discrimination; so many do not wish to know their status and some avoid telling their partner
they are HIV positive. This facilitates the spread of the disease because with HIV, it is very
important to start treatment as soon as possible for the best outcome. Further, once you begin
treatment with ART, your viral load is decreased, and you are less likely to pass on the virus to
someone else (8). That said, stigma in Swaziland has been decreasing recently, especially since
prominent figures began encouraging testing and have become role models by being tested
themselves. Examples of this include the traditional healer Chief Madelezi Masilela, who
recently admitted to being HIV positive due to widow inheritance, as well as banking executives
and workers from Nedbank and Standard bank and various pastors who publicly went to be
tested in order to raise awareness and try to change this social norm (1).
Understanding of HIV causality within the Swaziland population tends to be quite good,
though this does not always translate to behaviour change. There have been a variety of surveys
carried out to examine knowledge of HIV (including causality, modes of transmission, intended
behaviour change, etc) within Swaziland (4). Examples of this include the 1991 Project Hope
and Family Life Association of Swaziland (FLAS) Knowledge, Attitudes and Practices Study,
the 2003 National Behavioural Study, and the School HIV/AIDS and Population Programme

(SHAPE) baseline study (4). In these studies, people of Swaziland had high knowledge of the
true transmission of the virus (90-97%). 55% believed that AIDS was a serious disease, 70%
thought it was a serious threat to community, and 73% thought it would be in the future (4). The
Swaziland population also had accurate information about how to avoid it, with 80% agreeing it
could be prevented with behaviour change. Therefore, Swaziland individuals have good
knowledge of the emergence and spread of HIV. Less encouraging, however, is only 9.5%
reported that they planned on changing their behaviour. It is also important to note that the
studies largely reported that school age children were more knowledgeable about HIV/AIDS in
general than their teachers and parents, who reported more confusion on some aspects of the
virus (4).
Swaziland has made many efforts to lower HIV rates since King Mswati III declared
HIV a national crisis in 1999 (11). The government and a variety of non-state actors have
worked to implement many different programs. The National Emergency Response Council for
HIV and AIDS (NERCHA) leads the response at a national level, and has created three strategic
plans spanning from 2000 to 2014. There are also regional and community organizations that
work under NERCHA. Currently, NERCHA is informed by the National Strategic Framework
(NSF), which focuses on four main areas: prevention, care and treatment, impact mitigation and
response management (11). However, prevention of new HIV infections is the main focus of the
NSF.
The Swaziland Government first launched an initiative to provide ART to all patients in
2003, aiming to lower morbidity and mortality rates (11). The only criteria is that a patient needs
to have a CD4 count of lower than 350. (CD4 stands for cluster of differentiation 4, and is a type
of immune cell which lowers in number as HIV progresses.) The program mainly focuses on

first-line therapy adherence as they have limited options for second and third line drugs due to
resource constraints. Swaziland has had a recent growth in the availability of ART: from 70
facilities in 2008 to 133 in 2013, with an attempt to decentralize so that the therapy is accessible
in more areas (11). Examples of these strategies are designating decentralized areas as therapyrefill points so that refilling medication is more accessible. There has also been a focus on
engaging and training nurses in ART, so that there are a greater number of available health
personnel (11). There has also been an effort to implement pre-ART services, so individuals who
are living with HIV but have a CD4 count greater than 350 and cannot yet start therapy, will be
monitored so that the intervention can begin promptly when they become eligible. In 2013, 186
of 252 health facilities in the country had ART programs, and 169 provided pre-ART programs
(11). The effort has paid off as Swaziland is now one of just five Sub-Saharan African countries
to have more than 80% of those eligible for ART on treatment (6). This is significantly
decreasing the mortality rate in the country (1). Swaziland has also seen an improvement in the
available technology and drug therapy to treat tuberculosis (Tb), the most common opportunistic
infection that occurs at the AIDS stage of infection (11).
Many people in Swaziland opt for traditional healing instead: it is predicted that 85% of
the population makes use of healers services, at least occasionally (5). There are predicted to be
approximately 5400 healers in Swaziland which fall under two different categories: the divinerhealer (sangoma, inyanga) and the herbalist (lugedla, inyanga ymetsi) (5). Diviners work with a
variety of spirits that each accomplishes different tasks. They are called to their profession by
ancestor-sent illness, and then find relief from this illness by performing the duties of a diviner,
as a way to channel the spirits for good (5). They may also prescribe different herbal remedies,
but the main focus is on the spirits. Herbalists are separate from diviners in that they do not have

relationships with spirits, instead, they focus on the body and may make diagnoses and prescribe
herbal remedies (5). Healing is often done in ceremonies or rituals.
For many people in Swaziland, at least traditionally, illness is believed to be caused by
sorcery or anger of ones ancestors, who then withdraw their protection. Many Swazis may also
combine traditional (those treated by healers) and modern or Western medicine (that treated by
doctors). In a survey of healers, many said that there are certain diseases that should be treated
by doctors such as tuberculosis, cholera and heart disease. Further, 76% of healers surveyed said
they would send their patients to a doctor if they did not understand the source of their patients
illness (5). Many healers also said they admired doctors and their technology, especially X-ray
machines. Interestingly, 98% said they would like to practice more cooperation between
themselves and doctors and nurses (5).
The past few years in Swaziland have seen more collaboration between healers and
doctors. Beginning in 2003, Swazilands health ministry has held seminars for traditional healers
that share knowledge on HIV causation and transmission, and ways to decrease the spread of the
virus (12). Traditional healers tend to have large followings and great respect within their
communities, so they are an ideal resource to draw upon in the fight against HIV/AIDS. For
example, a cultural practice that involved cutting patients with a blade and rubbing medicine in
it was thought to contribute to the spread of HIV due to the inability to sanitize the blade
properly between patients (12). Due to these new partnerships between the healers and the
doctors, healers have now gone back to the traditional method of using porcupine quills, which
they do not reuse. Traditional healers now also distribute condoms at their practices, and are
helping to change cultural norms surrounding condom use (12).

Swazilands future in the fight against HIV/AIDS looks promising, though there is still a
long ways to go. The Swaziland government seems to be truly dedicated to lowering HIV/AIDS
rates in their country, as they have taken it upon themselves to finance all ART (11). The results
of these programs can be seen in the data. Firstly, testing rates have increased: from 16% of
those 15-29 infected in 2009 to almost 40% in 2011 (1). The rate of those being tested is
significant as this represents the first step towards treating the disease, and in turn, lowering the
incidence rate. This increase is largely linked to health infrastructure, but also to changing
norms and values and lowering levels of stigma (1). Further, condom use has improved from
56.8% in 2007 to 73.1% in 2011 of sexually active individuals using condoms consistently and
correctly. This is especially important as heterosexual sex is the main mode of transmission in
Swaziland (11). The incidence rate of disease has decreased significantly: from 2001 to 2011,
new infections have decreased by 37% (6). Another large success has been getting more than
80% of eligible individuals on ART, as well as more than 95% of pregnant mothers on ART,
which reduces mother-to-child transmission of the virus (6).
That said, there are still many areas that have room for improvement, particularly in
regards to social factors. The first area of improvement is in eliminating gender inequalities in
Swaziland, as well as gender-related violence. The country created a National Gender Policy in
2010 and passed the Sexual Offenses and Domestic Violence Bill in 2012-2013, but it still
remains to be seen if these are having an effect at changing social norms and beliefs, as there has
been no national survey to quantify this (11). Another area of focus is stigma and discrimination,
as a national survey showed that internal stigmatization of those infected is still at 26%, while
45% have not wanted to have children after becoming infected and 22% have stopped engaging
in sexual activities (11).

Swaziland has been hit hard by the HIV/AIDS epidemic, and has felt the effects. Though
it still has the highest prevalence rate in the world, the government has taken an active and
aggressive stance on HIV/AIDS, and the fruits of their labour show in the data. HIV/AIDS
incidence is decreasing in Swaziland, meaning that fewer people are becoming infected per year,
and therefore, the prevalence is deceasing as well. Based on this data as well as the overall
trends, one can assume that the epidemics morbidity and mortality rates will continue to
decrease, provided all current treatment measures in Swaziland stay in place. In the future, it is
likely that Swaziland will have to take a more aggressive stance in changing social norms,
though they have made progress in this field to date. With any luck, Swaziland will be the next
HIV success story, showing that even the highest prevalence rates can be overcome.

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