MBABANE, 23 February 2009: HIV prevalence in Swaziland shows signs of stabilizing. Results of The 11^th HIV sentinel survey of pregnant women released by Minister of Health Hon. Benedict  Xabaat a meetingattended by over 50 people from development partners, government officers, PLHIV associations, civil society, FBOs and implementing partners involved in HIV on the 20^th February 2009, shows that 42% of pregnant women tested positive to the HIV virus, leading health authorities to conclude that while HIV prevalence in Swaziland remains high, it appears to be stabilizing.

The current findings and trends show that HIV prevalence is homogeneously distributed in the country. Prevalence trends in young women also suggest that new infections are not decreasing as much as it may be expected, hence the epidemic levels not decreasing. Care and support interventions may be leading to improved survival among infected as indicated by high and increasing HIV prevalence among older women in the 2008 survey.

HIV is one of UNDP key focus areas, and the country office will continue to play its role in providing support in creating an enabling environment for the response through increased support for human rights promotion and capacity building of the sectors to ensure that the country has the capacity to manage the HIV response.

The first case of HIV infection was reported in 1986 and it appears the HIV epidemic in Swaziland rapidly increased in the late 1990s. There were an estimated 185,005 people living with HIV/AIDS in 2007 and the Swaziland Demographic and Health Survey in 2006 estimated the prevalence in the population 2 years and above at 19% and among the 15-49 age group at 26%. 

The national response has been multisectoral guided by the national HIV AIDS policy and strategic plan which have been reviewed periodically. The response included   strengthening of leadership and coordination, promoting prevention effort and providing effective treatment, care and support for people living with HIV and impact mitigation.. 

The sentinel surveillance system was established in 1992 and surveys have been conducted biennially to monitor trends in HIV infection. A behavioural survey and a population-based serological survey have been conducted in 2002 and 2006 respectively.

The main objective of this surveillance is to establish the point prevalence and trends of the epidemic.

In 2008, the 11^th sentinel survey was done among pregnant women attending antenatal care services for the first time of that pregnancy. The survey was done in 17 sites that have been used since 2002. Personal particulars and HIV data were collected. .Testing for HIV and syphilis were done at the Mbabane National Laboratory.   Data entry and analysis was done at the SNAP, using Epi info. The sentinel sites routinely offer Prevention of Mother to Child Transmission (PMTCT) services and therefore, all women participating in the survey were offered HIV testing and counselling .

Main findings (Results)

A total of 1,876 were included in the survey and 58.7% were in the 15-24 age group, 96.7% were Swazi, 64.3% had gravidity of 2 or less and 83.3% had had at most two live births prior to the survey. While 45% of the women were attended in rural facilities, 84.1% of the women lived in rural areas.

The national prevalence of HIV infection among the pregnant women tested was 42.0% - 787/1876 (CI: 39.7; 44.2). Prevalence ranged from 38.5% in Shiselweni to 45.4% in Lubombo; 26.3% among the 15-19 year olds to 49.1% among those aged 30-34; Those who presented with first pregnancy had a significantly lower HIV prevalence. There were no significant differences in prevalence by marital status, level of education and residence.

A trend analysis using data from previous surveys indicates that the prevalence among pregnant women is showing some stabilization after rapidly increasing through the 1990s and slowing down after 2004. Although an increase was observed from 2006 to 2008, the increase was not significant.

Trend in the level of HIV infection among antenatal clients in Swaziland since 1992

The 11^th sentinel surveillance among pregnant women report was launched Friday 20^th February 2009 at Mountain Inn in Mbabane, Swaziland by Minister of Health and Social welfare Hon. Benedict Xaba. The national prevalence for women attending ANC in 10 selected sites that have been used since 1992.

The level of HIV infection among the tested women was 42%, ranging from 38.5% in Shiselweni to 45.4% in Lubombo. There was a notable difference between those who were attending for their first pregnancy, marital status, and education level.

Trends

According to the report trend analysis using data from previous surveys indicates that the prevalence among pregnant women is showing some stabilization after rapidly increasing in previous years.

ART and prevalence

The 11^th sentinel survey was done among pregnant women attending antenatal care services for the first time of that pregnancy. The survey included women on PMTCT, but did not disaggregate the data as such.  As the national ART programme increases it is speculated that ANC prevalence will remain high as more women are gaining access to PMTCT.  

Drivers of the epidemic

An article in the Swazi Times of Swaziland Monday February 23, 2009 sites Professor Alan Whiteside, stating that “Swaziland has a perfect storm of many issues coming together to create the worst epidemic in the world”. Drivers of the epidemic as identified in the joint review of the NSP 2006-2008, include; low condom use, economic and gender inequality, low levels of Circumcision (8% -Modes of Transmission study 2008), multiple and sometimes concurrent partnerships, STI prevalence continues to be high at 11% according to the DHS.  

Response

It is time for the country to return to the drawing board to reconsider our prevention strategies for a more effective response. 

Participants were drawn from key UN and NGO partners from RIACSO as well UNCT representatives from Angola, Botswana, Zimbabwe, South Africa, Mozambique, Zambia, Malawi, Swaziland and Lesotho. The workshop was convened by WHO, UNICEF and OCHA

Swaziland was represented by Joseph Mutsigwa, UNDP Disaster Risk Reduction Specialist; Dr. Benjamin Gama, WHO HIV/AIDS National Professional Officer; and Dr. Victor Ankrah UNICEF Health and Nutrition Specialist.

• Build a common understanding of the cholera crisis in the region, including compounding factors, such as floods and cyclones, chronic food insecurity, HIV/AIDS, political instability and insufficient service delivery;
• Develop a comprehensive and shared analysis of risk factors and possible scenarios;
• Update Inter-Agency Standing Committee priorities, in support of Governments, for preparedness against this evolving backdrop;
• Identify possible material, financial and human resource gaps and plans to address these gaps;
• Elaborate a common strategy to engage SADC in addressing the crisis.

• Access to safe water overall improved, but not to MDG levels
• In most countries, millions (mainly urban and rural poor) still don’t have access

• Steady improvement except in Zimbabwe where sanitation has gone down. Speed of improvement in sanitation is very low.
• Tens of millions of people don’t have access to sanitation

• Poor purchasing power is impacting on maintaining hygiene

Cholera outbreak in Southern Africa is a manifestation of many compounded, underlying and longstanding vulnerabilities viewed in the context of:

• Climate change;
• Migration;
• Food security;
• Rising poverty; and
• Socio-political unrest

In the current context, any increase in acute watery diarrhea constitutes an emergency, requiring a robust response from the Government, with support from the international humanitarian support. Trends indicate a need for fast and clear action in three key areas that require multidisciplinary response in order to contain the epidemic. If multidisciplinary approaches fail, the costs to governments will far exceed capacities and more people are likely to die.

a. Undertake a rapid diagnostic of implementation of standards in all countries

• Are coordination mechanisms in place?
• Are partnerships in place? (Community-based care networks)
• Do you need any specific technical support?
• Are protection needs adequately addressed? Best practice: Zim/watsan.
• Are your current capacities and resources enough to get through the next three months? (Will inform resource mobilization strategy)

b. Assess enabling actions the Government needs to take to improve the timeliness of the response

c. Develop and/or operationalize cholera component of IASC contingency plan (Best practice: Swaziland)

• Immediate resource mobilization to support SADC in regional surveillance
• Immediate mechanism to better share information between Zimbabwe and surrounding countries

• Unimplemented protocols (WHO)
• Migrant health strategy (TB, malaria, HIV). Expand to epidemics.
• Encourage strong declaration of outbreak and better exchange information (political / IM challenges that hamper response)

c. Provide countries with technical guidance to develop comprehensive approach:

• Immediate request from RDT for injection of global lead capacity to support countries (1 month)

• provide joint technical level support missions to countries; and
• Continue regular telecon to determine response to each new outbreak

 e. ERC to write RCs in the region

• You need to forcibly engage Governments

 f. Create regional stockpile

·         Consolidate cooperation on cross border issues between and among countries.

• Angola – Namibia
• Angola - DRC
• Malawi – Mozambique
• Swaziland – Lesotho – South Africa

• Assessment of structural, policy and capacity challenges. These could be addressed through the UNDAF.

The law plays a central role in promoting and protecting the human rights of all citizens.

Swaziland currently has a dual legal system of government where, there is co-existence between the modern and the traditional system of government. These two systems have, legitimized the establishment of two court systems; modern and traditional which citizens can go to and obtain recourse in matters where they have been unjustly treated.

These two court systems operate independently of each other, with the modern courts enjoying more status than the traditional. National Court Presidents preside over traditional court. The traditional courts normally adjudicate over cases related to family disputes including domestic violence and petty crime. The traditional courts are known for their quick adjudication of cases as opposed to the modern courts, which often take a considerably longer period of time to reach a decision. However traditional courts have a limitation in that the national court presidents do not necessarily have a formal legal background although they do possess have considerable knowledge of customary law. This lack of legal training tends to create a lack of uniformity in the operations of their work, and compromises their ability to fully play their functional role as adjudicators.

The enactment and implementation of the new constitution has resulted in an increased demand on all legal service providers, but particularly the services provided by National Court Presidents. In order to provide appropriate rulings in line with this new reality, National Court Presidents must draw reference from or consider the relevant provisions of the constitution in the execution of their duties. Thus the constitution becomes a very important document in the operations of National Court Presidents, since it spells out the rights of people and a wide range of issues, which often come under their jurisdiction.

It, therefore, has become imperative for the National Court Presidents to increase their knowledge of the constitution and other human rights issues that relate to their work. This is especially important since given their quick turnover on cases, they are responsible for making decisions on a large number of national cases. In this regard, the decisions made by national courts affect the majority of the Swazi population. 

UNDP supported a series of training for National Court Presidents on the constitution and human rights. 

Individual reviews revel that National Court Presidents found the trainings beneficial and are using this knowledge. An assessment will be conducted this year as a follow up to the training conducted.      

MBABANE 12-2-2009: HIV partners in Swaziland are looking forward to an improved national HIV outlook for the first time in the next meeting of the Swaziland Partnership Forum on AIDS (SPAFA) to be held in the next two weeks.

The meeting which is supported by UNDP as part of its support for coordination and strengthening of partnerships in the national response will provide the first update after the last SPAFA meeting in which trends from a number of areas indicated an improvement in the national HIV picture.

Since 1992, national prevalence was calculated using data from women attending ante-natal care points. Prevalence figures over the years have shown exponential rise from 3.8 in 1992 to a peak of 42% in 2004. Prevalence declined slightly to 39% in 2006.

A Demographic Health Survey was subsequently introduced and its first report in 2007 showed a national HIV prevalence of 18.2%, and 26% for the sexually active 15-49 age group. A glimmer of hope in the DHS analysis suggested that the number of people who know their HIV status in the 15-49 age group had increased to 50 % for men and to 25% for women.

It also showed that correct and consistent condom use within the same group had increased by 80 % for both men and women and comprehensive knowledge on HIV prevention also showed improvement for the age group 15-24.

Most important though, the study showed an improvement in the most sensitive area of HIV prevention in the country. The number of multiple partners reported among men 15-49 years old had decreased from 22% to 15%, and the national capacity to manage and coordinate national response to HIV prevention improved.

Anxiously awaited, is the 2008 ANC report which is believed to be imminent. It is expected to confirm or dispute widespread perceptions that the prevalence rate, which currently stands as the highest in the world, has stabilized, and may perhaps begin to decline.

SPAFA is a high level coordination quarterly meeting chaired by the Prime Minister and attended by 80 high level policy makers including government, development partners, civil society, PLHIV and implementing partners. It is aimed at bringing together policy makers to discuss the national response.