The silent war: how and why HIV almost wiped out Swaziland

Swaziland remains one of the few countries on the African continent not to have faced war. As different countries were ravaged by either liberation or civil wars, Swaziland remained shielded from the devastation caused by internal strife.

With a population slightly over 1.2 million people, the country is nestled at the Southern tip of the continent landlocked between Mozambique and South Africa. Swaziland became known as the ‘Switzerland of Africa’ not just because of its beautiful climate, rolling mountains and beautiful natural scenery, but also because it is of the few countries in Africa that is ethnically and religiously homogeneous. It prides itself for always prioritising peace.

However, in recent decades and beneath punting itself as a ‘peaceful’ nation, Swazis have been facing a much more sinister war with devastating consequences—the war against AIDS.

So serious is the HIV problem that at 27.2 percent Swaziland has the highest HIV prevalence rate (among adults aged 15 to 49) in the entire world, at least according to the 2016 official statistics.

The United Nations Human Development Index  reports that as a consequence of the virus, life expectancy  fell from 61 years in 2000 to 32 years in 2009. The 2002 World Health Organization (WHO) data alarmingly records that 64 percent of all deaths in the kingdom were caused by HIV/AIDS.

The United Nations Development Program has reported that HIV/AIDS has reached epidemic proportions in the Kingdom and that if this state of affairs continues unabated, the “longer term existence of Swaziland as a country will be seriously threatened“.

These statistics are by all accounts mind blowing. If anything, they show that as populations in other African countries faced and continue to  face deadly muzzles of rifles, artillery guns and bombs; graves in Swaziland continue to be filled at an equal rate as countries engaged in military violence.

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Swaziland has had one of the worst HIV/AIDS epidemics in the world, but since 2011, the massive scale-up of testing and treatment has slashed the rate of new infections by 44 percent.

How did such a small country get to have such a high prevalence rate than the rest of the world? Should we be concerned that credible UN agencies warn that the “longer term existence of Swaziland as a country will be seriously threatened“?

In Swaziland the first recorded case of HIV was in 1986 and three decades later the virus has hit the nation like a plague of biblical proportions.

After all, 210,000 of the 1.2 million people in Swaziland are HIV positive. According to statistics, 7 000 people are infected every year.   Meanwhile, in Norway, a country similar in Swaziland more ways than one, the prevalence rate is at just 0.1 percent.

In fact, by 2016 only 216 people were infected in Norway. There are lot of similarities one can draw about the behaviour of the virus in Norway and Swaziland.

These similarities can be drawn from the fact that both countries have relatively small populations (off course one is super rich and another extremely poor); both have kings and both are relatively homogeneous societies.

 In Norway HIV infection rates were high in the late 70’s and four decades later it is almost non-existent. On the other hand, the virus peaked in Swaziland around the late 90’s and is today considered the second biggest killer. What then could possibly explain this?

It is easy to be tempted to deduce that Norway’s success in fighting HIV to owes to the fact that it is a high income country. However, that would be a simplistic and narrow argument. If that was the case, South Africa would not be having the highest number of HIV positive people in the world because it is Africa’s biggest economy and a middle income country.

This requires us to then probe even deeper why the virus is behaving differently this side of the globe. In this regard perhaps we should note the views of Thabo Mbeki, the former President of South Africa,  who argued that the behaviour of HIV in South Africa, – and perhaps by extension Swaziland, which not only shares a border with South Africa, but is similar culturally, socially and even economically – could have something to do with that country’s peculiar socio-economic conditions.

Part of Mbeki’s argument in the early 2000’s was that people were dying because of poverty and the toxicity of the Anti-Retroviral Treatment (ART) drugs of that time. It is worth remembering that ARTs used to cost about $1000 a person per year.

Mbeki argued that instead of spending so much money on the drug it would be wise to invest in creating conducive socio-economic conditions for the people to live a healthy life. 

Mbeki’s views were bastardised in the press to fit particular agendas but none dared to answer questions he asked on why the virus behaved differently within the different races and classes of South Africa?  

Following the so called Mbeki debacle, the President’s Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to fight HIV, TB and Malaria were formed.

This development came with two positive outcomes: first, the drastic reduction in the cost of ARV, secondly, it granted universal ART access in many developing countries, Swaziland included. It is for that reason that Swaziland has an ART coverage rate of about 87 percent and viral load suppression among those on ART at 91.4 percent.

If the above is true then why does Swaziland have 7000 new HIV infections per year? The logic here is that if you have good ART coverage it should follow that new infections should be drastically reduced.

 Recent research studies show that new infections have been halved by boosting access to virus suppressing drugs but still this needs further examination. 

When broken down, the statistics show very poor treatment outcomes among young people, at only 50 percent of those on ART having Viral load transmission.

Clearly ARTs alone is not the panacea to Swaziland’s nightmare. Other factors need to explored which, if addressed, may yield positive results and stop the country from being wiped out by the virus. 

The government needs to address the socio-economic causes that make HIV thrive. The first step would be eradicating poverty. ARVs tend to increase a patient’s appetite. The drugs rely on food for their efficacy, they must be taken with meals.

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S’bongile Hlophe, one of the leading campaigners against HIV/AIDS in Swaziland. HIV infection rate peaked in the late 90’s in the country.

What happens then to those patients in Swaziland who live in abject poverty, who at times go for days without eating, yet have to take their medication consistently? Poverty then hinders the drug’s effectiveness.

Linked to the issue of poverty is the need to address unemployment—youth unemployment specifically. As it stands, in Swaziland, 54 percent of young people between the ages of 16 and 35 years are currently unemployed.         

Slashing university allowances and funding in 2011 was by far the worst thing the government of Swaziland did, as this worsened the non-ability for youth to get trained and find employment.  

The pressure to the girl child is double fold. Poverty makes women more vulnerable and to survive many are forced into habits that place them at risk. These habits makes them vulnerable to being prayed upon by rich males who sometimes sleep with them without protection thus spreading the virus.  

Young girls around the ages 15-24 are statistically four times likely to be infected than their male counterparts. The question that begs answers then is where are they getting the virus? It is definitely not their age mates. Perhaps, this suggests inter-generational sex as a factor.

Most of these girls get into relationships not because of mutual affection but for survival, especially in these hard economic times. In such an arrangement, chances of bargaining for condom use are next to zero. In essence, the woman is always at the mercy of the ‘Blesser’.

We must also factor in the fact that women or young girls are traditionally expected to take care of their sick family members when they are bedridden. They are the ones who nurse the open wounds and in some instances without gloves thereby exposing them to HIV transmission.

Until recently, marital rape was not punishable by law  in Swaziland and women could not refuse their partners conjugal rights, even when they knew this came at a huge risk to their lives. 

This was especially worse for women in polygamous relationships because their husbands would add an HIV positive partner to the harem and then sleep with all the other wives without protection.

Men would come home to have sex with their wives often without enough foreplay (read little lubrication for the vagina) hence increasing the risk of bruising— a portal of entry for HIV transmission. Some women have reported that such men refuse to use a condom.

It is clear that if Swaziland is serious about meeting the 2030 sustainable goal (as it relates to HIV) there needs to change in mindset and policy regarding including commercial sex workers, sexual rights of prisoners, sexual orientation, gender identity and expression (SOGIE), young girls and women.

The laws that prove to be barriers for these groups’ accessing quality health services need to be revised. In the final analysis, it cannot be ignored that the reality is that at the core of the HIV problem in Swaziland is poverty and a system of governance that systematically fails to prioritise the nation but prioritises the King and his extended royal family.

NB: This article was a collaborative effort between the author and Thabo Dlamini, a Masters students at the University of Bergen in Norway. Both are nurses  and former leaders of the Swaziland Union of Students (SNUS).

Thembelihle Dlamini

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