Despite the Swazi government's claim that it is hitting its targets as it rolls out life-prolonging ART (antiretroviral therapy), HIV/AIDS activists warn that the government may be aiming too low and that serious challenges remain, particularly regarding women.

There were over 15,000 patients on the programme, but this number was expected to double by the end of the year, the ministry of health told a conference on ART this week in the central commercial town of Manzini. The discussions were attended by health NGOs, government health officials and people living with HIV and AIDS.

AIDS organisations said the drugs were reaching only a fraction of those who needed them and targets should be radically raised.

Increasing the availability of ARV (antiretroviral) drugs in a country with the highest HIV prevalence rate in the world has become a matter of urgency. According to UN estimates, 33.4 percent of Swazis between the ages of 15 and 49 are HIV positive.

"In a broader, non-gender view, there are far fewer ARVs being distributed than HIV-positive people who need them, but this is because most Swazis do not know their HIV status, and don't wish to know," Albertina Nyatsi, the HIV-positive head of the Manzini-based NGO, Positive Women together, told IRIN.

Thembi Nkambule, National Coordinator for the Swaziland National Network of People Living with HIV and AIDS (SWANNEPHA), pointed out that "There is a need to make ARVs more available to children, and to develop a national ART literacy curriculum, and an urgent need to scale up community awareness around the accessibility of ARV drugs."

According to Nyatsi, "Information on ARVs still remains inaccessible for many Swazi women living positively. Most information is generalised, and needs to be tailored for women-specific needs."

Challenges remain

Other urgent issues discussed included ensuring continuity of drug supplies, affordability of medicines, and the finalisation of national nutritional guidelines defining proper nourishment for people living with HIV and AIDS, particularly in the context of poverty. Official estimates put the number of people living on less than US$1 per day at approximately 70 percent of the population.

The 'hidden costs' of ARV treatment should also be recognised and addressed. "Transportation is a big cost to many Swazis," Nyatsi said. "They have to go to clinics far away to collect ARVs, and get ... testing and counselling. The medications may be free, but transportation is a significant hindering factor for access to ART."

The biggest obstacle to the success of the programme, according to Nyatsi, was uncertainty about whether people were adhering to their treatment by regularly taking the correct dosage.

Religion and tradition

A report compiled by the National Emergency Response Council on HIV/AIDS (NERCHA), based on a similar conference in May, claimed that some church leaders and traditional medicine practitioners, groups which both have great influence in Swazi society, were misleading parishioners and clients.

"Even pastors from the religious sector are disseminating information in their churches about HIV/AIDS that is not always factual and in line with the stipulations of the national policies," the authors alleged.

"Some traditional healers are making concoctions that are mixed with ARVs, and these remedies are taken by people living with HIV/AIDS, heightening the risk of drug resistance and reversal of progress gained by the national ART programme rollout."

Women particularly vulnerable

The NERCHA report, circulated at the conference, also claimed that hospital and health clinic nurses who attended pre-natal patients were advising HIV-positive women not to have children, or to abort if they were pregnant and had a significantly low CD4 count, which measures the strength of the immune system.

Abortion is outlawed in Swaziland, but patients are often advised to travel to neighbouring South Africa for the procedure.

Thandi Simelane, an HIV-positive woman, told IRIN: "The nurses say that there are not enough ARVs, and treatment is still poor for people living with HIV/AIDS. I can understand their frustration, but this is advice hard to take by Swazi women. Having children is very important to us. It is life itself."
According to Nkambule, "Women still have the right to choose to have children. It is not up to the person who is treating you to tell you whether or not to have a child.”

Although the constitution guarantees gender equality, traditional society has yet to embrace the concept, putting additional pressure on HIV-positive women. "Besides living with the stigma of being HIV positive, most women are restricted by family members and husbands from going on ART because of the expense," said Nyatsi.

Despite considerable budget constraints, the Swazi government has allotted R43 million (US$6.25 million) to the national ART programme.