Swaziland - a Nation at war with AIDS

”People no longer accept that the sick and dying,
simply because they are poor, should be denied drugs
which have transformed the lives of others
who are better off”. (Kofi Annan, UN Secretary)

Swaziland attained well over 900% increase in HIV prevalence among antenatal care respondents within a decade (1992: 3,9% - 2002: 38.6%), despite massive prevention programmes.

As the HIV/AIDS pandemic is rolling back many of the social development achievements, it has been declared already in 1999 a national disaster by His Majesty the King. In search of a way out from the vicious cycle of HIV/AIDS, adequate assistance and support from within the country, but also from well-cooperating international NGOs such as the Swiss Red Cross are being mobilized and coordinated for effective prevention, care and treatment programmes. The struggle for positive impact is arduous, and problems and constraints are undoubtedly numerous. Despite limited resources, Swaziland is determined to apply whatever strategy is indicated to prevent the nation from being doomed within one generation.

The Impact of HIV/AIDS

Swaziland, with its small population of about one million people is arguably the world’s most affected country with HIV/AIDS pandemic. As the epidemic matures, the dreadful impact is becoming real in many ways:

• There has been marked rise of about 100% in the death rate up to 22.7 deaths per 1000 inhabitants.
• Morbidity has risen; more than 80% of hospitalised persons are due to HIV related illnesses.
• All improvements in health indices have been reversed, and they are increasingly worsening. Emigration of trained nurses and other health care personnel to more developed countries led to acute shortage of professional resources.
• The number of AIDS orphans has escalated to about 50 000 by the end of 2003. It is estimated that this will be 120 000 (approx. 15% of the population) by the year 2010!
• In the education sector 30% of eligible children will, by 2015, not enrol in school. The ratio of teachers to students has shifted from 1:35 in 1997 to 1:52 in the year 2000.
• The economy has suffered stagnation as a result of loss of skilled workers due to HIV infection.

Swaziland is undoubtedly on the brink of disaster, if its high prevalence rate of HIV is not immediately arrested by reducing stigma and discrimination, providing care and treatment to the people living with HIV/AIDS (PLWHAs).

Strategy and implementation of antiretroviral therapy in Swaziland

The advent of potent antiretroviral therapy (ART) in 1996 led to a revolution in the care of patients with HIV/AIDS in the developed world. Although these treatments are not a cure and present new challenges of their own with respect to side effects and drug resistance, they can dramatically reduce mortality and morbidity rates, will improve quality of life, revitalize communities and transform perceptions of HIV/AIDS from a plague to a manageable, chronic illness.

In Swaziland, it is estimated that there may be between 20 000 to 26 000 people living with HIV/AIDS who are in urgent need of antiretroviral treatment. The national target for emergency antiretroviral therapy programme is set to put 13 000 AIDS patients on ART by the end of 2005.

Although Voluntary Counselling and Testing services have been available for some time in the country, provision of ART to people living with HIV/AIDS only began in November 2003. – In fact, 2003 is the turning point in the fight against this fatal disease in Swaziland. Apart from the provision of free antiretroviral drugs at two treatment sites in Mbabane, the prevention of mother to child transmission (PMTCT) has been launched through an integrated pilot programme by Swazi and Swiss Red Cross in rural Swaziland.

In the public sector provision of antiretroviral therapy started late 2001 in Mbabane Hospital but it was only until November 2003 that free-of-charge antiretrovirals were offered to the public. At present, about 2000 patients are under treatment.

Stakeholders

The National Emergency Response Committee on HIV/AIDS (NERCHA) was established in 2001 to enhance the coordination of the national response to the epidemic and to foster the wider multi-sectoral involvement of other stakeholders. NERCHA is a semi-independent body that coordinates and secures funds from the Global Fund to fight AIDS, Tuberculosis and Malaria (GFATM).

Various UN agencies EU and the Italian Cooperation serve as technical partners in strengthening the monitoring and evaluation capabilities. NGOs such as Swaziland Red Cross Society with the support of Swiss Red Cross, Swaziland AIDS Support Organisation (SASO), Swaziland Infant Nutrition Agency Network (SINAN), The AIDS Information and Support Centre (TASC), Family Life Association of Swaziland (FLAS), and AMICALL are indispensable because of their extensive community participation.

The PMTCT pilot programme funded by Swiss Red Cross

The pilot programme of prevention of mother to child transmission is actually a comprehensive treatment programme based in Sigombeni rural clinic near Manzini which includes pregnant women and their family members. The entry point into the programme is through Voluntary Counselling and Testing which is manned by well-trained counselors who in part come from the community of people living with HIV/AIDS.

Seropositive pregnant women are given a single dose of Nevirapine at the onset of labour. Their babies will also receive Nevirapine within 72 hours of birth. Counselling is provided on infant feeding option. Prophylactic medicines such as Co-trimoxazole is provided to all infected persons and babies exposed to HIV. Triple regimen therapy is given to all infected persons that meet the set down criteria for treatment.

Regarding the monitoring process, simple investigations are being done at the programme site. Other investigations such as CD4 / viral load, PCR for babies and resistance testing will be done at the National Laboratory Centre in Mbabane. Monitoring within the community is done by trained Care Facilitators who monitor compliance, provide information to assist adherence, and report early signs of toxicities to the physician or the nurses. The Care Facilitators will also undertake regular visits to the patients in order to assess and report any mitigating factor in the household. Maternity service will be provided at the site by experienced midwives and prompt referral of complicated cases is to a nearby tertiary care centre.

Challenges to scaling up access to antiretroviral therapy

Though prevention will remain central to all HIV interventions, universal access to antiretroviral therapy for everyone who requires it according to medical criteria will open up ways to accelerate prevention in communities in which more people will know their HIV status – and, critically, will want to know their status.

Rolling out effective HIV/AIDS treatment is the single activity that can most effectively energize and accelerate the uptake and impact of prevention. Attitudes will change, and denial, stigma and discrimination will rapidly be reduced.
The Ministry of Health in collaboration with NERCHA and other relevant stakeholders mentioned above will be scaling up access to ART by infected persons. This is done by a first pilot phase from February to July 2004, based on the emergency ART implementation plan of action developed in September 2003. Based on the pilot experience, the implementation of a medium- to long-term strategy will follow.

The challenges to scaling up antiretroviral therapy in Swaziland are great. Sustainable financing is essential. Drug procurement and regulatory mechanisms must be established and strengthened. Health care workers must be trained, infrastructure improved, communities educated and diverse stakeholders mobilised to play their part.

In medical terms, one of the major challenges will be to avoid resistance by adequate treatment and continuous patients’ information.

Human resources for health: Shortage of human resources capacity is a real crisis in Swaziland.

Medicines and diagnostics:: The system to ensure continuous supply and distribution of AIDS medicines and diagnostics is not in place. Though the country received the first disbursement of the GFATM grant in July 2003, purchase of AIDS medicines has been hampered by bureaucratic bottlenecks and technical difficulties.

Children, HIV/AIDS and Nutrition: Paediatric treatment guidelines are currently underdeveloped and should be updated and included in the national guidelines. Consent and modalities for testing and treatment of orphans and vulnerable children living with HIV/AIDS are also required. Food security is a major problem in Swaziland for both adults and children; providing food supplements with ART is therefore essential.

Health workers and ART: Swaziland has a post-exposure prophylaxis policy in place but currently there is no implementation plan and health workers have limited access to prophylaxis.

Laboratory: The laboratory capacity seems to be well developed, particularly at central level. However, much work needs to be done at regional and health centre level.

Communication and Media: An integrated strategy for information, education and communication is not in place and misinformation regarding HIV/AIDS via the media is common.

Collaboration and Coordination: There are many partners interested in the 3 by 5 initiative and, to maximize the effectiveness and efficacy of their contributions, strong coordination is required.

Community Involvement: There remains much potential for mobilizing members to support ART for people living with HIV/AIDS.

Monitoring and Evaluation: Simplified appropriate systems are required to monitor and evaluate care and treatment activities and ensure effective programme implementation.

Conclusions

In the face of the challenges, many pilot projects have shown that safe and effective antiretroviral treatment can be delivered in resource limited settings. It is also observed that the availability and accessibility of antiretroviral treatment contributes to significant reduction in stigma and discrimination.

Swaziland is a small and very poor country, which is saddled with a phenomenal disease that is rampaging through every facet of its society and well-being. In fact, its survival depends on immediate and exceptionally effective prevention, treatment and care programmes to reduce deaths from AIDS, reduce the number of new orphans, reduce the number of new infection, prolong life expectancy and improve the quality of life. The Swaziland Government and its political leaders are doing everything within their means to fight this menace, but without support, financial and technical partnership from the International community their efforts might be largely negligible.

*Dr. Jamiu O. Peleowo is a General Practitioner who treats and manages a number of PLWHAs in the capital city of Swaziland. He holds a Masters degree in Public Health and a Post-graduate Diploma in Public Health (HIV/AIDS). Dr. Peleowo is a member of the Baphalali Swaziland Red Cross Society’s HIV/AIDS Advisory Committee, and heads the clinical aspect of its PMTCT programme supported by the Swiss Red Cross. The PowerPoint slides of his presentation are available on the http://www.medicusmundi.ch/aidsfocus/conference2004/docu.htm website. Contact: iz@redcoss.ch