Average life expectancy in Swaziland has plummeted from around 60 years in the 1990s to just over 30 years today. Few would deny that HIV/AIDS is largely to blame, but the reasons why the epidemic has devastated this tiny, southern African country more than any other are less clear.
"Foreign observers look at Swaziland and can't figure out why the numbers [of HIV infections] remain so high," said Harriet Kunene, of The AIDS Support Centre in the central commercial town, Manzini. "There are many factors, and they also explain why the problem is a long-term dilemma that doesn't lend itself to short-term or easy fixes."
Epidemiologists and those working at the coalface of the epidemic cite various historic and socio-economic factors that have combined in Swaziland to create ideal conditions for the spread of the virus.
A well-documented disdain of condom usage – one UN report found that 60 percent of Swazi men refuse to wear them – is one explanation for why 42 percent of pregnant women tested HIV positive in a 2008 antenatal survey.
"Many women tell us, even if their men begin by using a condom, by the end of the act it has slipped off or been removed, and they have no power to insist," said Pholile Dlamini, who runs the Manzini office of the Alliance of Mayors Initiative for Community Action on AIDS at the Local Level (AMICAALL).
But other factors have also contributed to the grip HIV has on this country of less than one million people. "Swaziland is so small [just 17,363 sq km] it is easier for the virus to spread," said Rudolph Maziya, AMICAALL's national director.
"If a party is thrown in Johannesburg, a South African in Cape Town is not likely to attend. But when you have a party in Manzini, people from the farthest corners of the country show up; the social-sexual networks have always existed in Swaziland, and they made the spread of HIV easier."
In 1993 Maziya worked on a report that accurately predicted the trend AIDS would take in the next decade. "It was rejected by parliament, and many health officials condemned it as alarmist. Meanwhile, HIV spread because no one could see it. With Ebola [haemorrhagic fever] or swine flu, symptoms are immediate; people don masks. With HIV, symptoms may take years to appear."
Faith Dlamini, programme officer at the National Emergency Response Council on HIV and AIDS (NERCHA), which disburses government and donor funds to local AIDS organizations, pointed out that seasonal migration of workers was another driver of infection. "It is why AIDS is so high in the sugar belt, where there are many seasonal workers who leave their homes for months at a time - they find accommodation where they can, and also find lovers."
Pholile Dlamini agreed. "Women tell us they just accept that their husbands have girlfriends when they are away, and there is nothing they can do about it except try to protect themselves when their husbands are at home. But they are not entirely successful - condoms are distributed free everywhere; people take them, but they don't use them."
With unemployment estimates ranging from 25 percent to 40 percent, and "underemployment" widespread among those who have jobs, Faith Dlamini said poverty was also driving the spread of HIV. "We are tracking women workers in the industrial areas. They are paid low wages and may have to turn to other methods to survive."
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Engaging in sexual relationships with older men is one form of survival that carries a high HIV risk for young women, but polygamy is legal in Swaziland and many middle-aged and elderly men marry teenage girls as second or third wives. "For girls it may be the only way out of poverty, or to acquire cash, a cell phone, clothes and other luxuries they see in the media," Pholile Dlamini commented.
Despite considerable efforts by government, NGOs and donors, Swaziland's AIDS epidemic is proving resistant to quick fixes. In this highly traditional society, resistance to change is so firm that Maziya believes nothing short of a "social revolution" will provoke behaviour change and, even then, it will be years before those changes are reflected in lower prevalence figures.
"This is a long-term matter," he said. "It is time we stopped treating AIDS in Swaziland as an emergency and see it as it is: a decades-long situation."
[This article is the fifth part of IRIN/PlusNews series on "Countdown to Universal Access"]