Prevention remains absolutely critical in the national response to HIV and AIDS. Investing in prevention also has collateral benefits in treatment care and support and in impact mitigation. So far, prevention efforts have not been effective enough to halt and start reversing the epidemic, and new infections continue to outpace the number of people placed on treatment.
Effective prevention interventions are those that are selected on the basis of empirical evidence of their efficacy in preventing new infections. They also collectively or individually target the key behavioural and biological drivers of the epidemic. The main mode of transmission in Swaziland is heterosexual; specific behaviours that put people at risk of HIV infection include multiple concurrent partners, low age of sexual debut, low and inconsistent use of condoms during sex in which there might be exposure to HIV, intergeneration sex, and commercial sex; and contextual factors that contribute are income inequality, mobility and migration, and gender inequalities. These epidemic drivers are discussed in detail in section 3 of the NSF.
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. It also observed that prevention interventions were being carried out as ‘business as usual’; they were not adequately informed by evidence, best practices, and consumer acceptability surveys. They were found to be frequently generic in nature and failing to address specific challenges within key populations. Equally, communities were found to be inadequately mobilised and not engaged in a meaningful manner to ensure their active and sustained participation, involvement, commitment and retention in prevention initiatives.
For objectives and targets under PreventionRefer to National Strategic Framework (NSF).
Treatment, Care and Support
HIV has severely impacted mortality and morbidity trends in Swaziland. According to the 10th Sentinel Surveillance Report, the crude death rate in Swaziland has increased as a result of AIDS mortality from 9.9 to 22.7 deaths per 1,000 population and is projected to reach 30.2 deaths per 1,000 population by 2011. WHO estimated that in 2006, 64% of all deaths in the country were due to AIDS (WHO 2007). Life expectancy at birth has fallen from 56 years in 1997 to 40.2 years in 2008
Compounding the HIV disease burden is the high and escalating Tuberculosis (TB) epidemic. TB is a leading cause of death for PLHIV in the country given the high HIV/TB co-infection (80%, MOHSW (2006). Multi-drug-resistant (MDR) TB and extensively drug resistant TB (XDR-TB) have been identified in some patients. In 2007, 98 cases of MDR-TB were identified. The death rate amongst patients with MDR-TB is estimated at around 30%, while the death rate associated with XDR-TB is around 50% (Brandon Keim 2008).
HIV treatment, care and support should be provided by the health sector for people living with HIV, to help reduce morbidity and mortality due to HIV and AIDS and to improve their quality of life. The health sector is defined to include public and private institutions and traditional health systems providing health care services in the country. It also includes alternative medicine that has not been formally integrated in the health sector. It is anticipated that implementation of the interventions outlined below will result in more years of healthy life. Quality of life requires detailed surveys, so the following simpler impact level result for treatment, care and support was selected:
For objectives and targets under Treatment, Care and Support
Refer to National Strategic Framework (NSF).
The impacts of HIV and AIDS are felt across all sectors of society and economy. The impacts at household, homestead, and community levels, are reflected in growing food insecurity, deepening poverty, narrowing of livelihood options, loss of socio-economic support networks, and weakening of delivery systems intended to support livelihoods improvement (FARNPAN, 2007; WFP, 2007). One-fifth of the population is chronically reliant on food aid, and 30% of the rural population is reported to be food insecure (World Bank, 2007).
The epidemic has increased mortality and morbidity. The National Plan of Action for OVC estimates the number of vulnerable children to be 130,000 of whom 70,000 are orphans. In the 2005/06 Budget speech, the Minister of Finance in Swaziland stated that high unemployment, food insecurity and HIV and AIDS had together resulted in a 3% increase in poverty in the last fiscal year. The latest estimate of life expectancy is 40.2 years (40.4 for women and 39.9 for men). It is anticipated that the annual population growth rate will decline from 2.9% in 1997, to about 2.1% by 2015. AIDS is robbing communities of their bread winners, leaders and the knowledge and skills necessary to sustain livelihoods. Because of this, HIV threatens traditional family and community coping mechanisms (safety nets) and food security. Swazi families are organised around a homestead system, with multiple households living in a single compound (or within a limited geographical area around a main compound. The homestead system offers support to extended family members, a mechanism to protect households from social and economic challenges that could undermine livelihoods.
As more people succumb to the epidemic, a vicious cycle is created - the capacity to absorb and utilize existing resources for socio-economic development is reduced contributing to deepening poverty. Increased expenditures on health care and funerals, and lower income (due to morbidity) reduce personal savings and investment, and increase overall health care and labour costs. The Gini Coefficient shows a sharp rise in income inequality to 60.9 on a scale of 1 to 100 (with 1 representing full equality and 100 full inequality), from 51 less than a decade earlier (World Bank, 2007).
Although it is difficult to measure the specific impact of HIV and AIDS on agriculture, it is generally accepted that the epidemic is reducing productive capacity through people falling sick and becoming unable to work as well as through absenteeism to attend funerals or provide care. The cost of replacing highly skilled personnel is high, especially in skills-scarce economies such as Swaziland. AIDS is reversing the socio-economic gains since independence, compromising investments in health care, education, agriculture and human capital.
For objectives and targets under Impact Mitigation
Refer to National Strategic Framework (NSF).