Poverty erodes treatment gains

2008 was a difficult year for people living with HIV in Swaziland. The cost of food and transport rose steeply, and supplies of antiretroviral (ARV) drugs and medicines for treating opportunistic infections ran low in public health facilities.



"Last year was a crisis," said Maphangisa Dlamini, a home-care nurse at Swaziland Positive Living for Life (SWAPOL), an AIDS support organization that joined demonstrations protesting the perilously low supply of ARVs.



"I think at this point there is improvement," he told IRIN/PlusNews. Government has more than doubled its health allocation, from 10 percent of the national budget in 2008 to 17.7 percent in 2009.



Money has also been allocated to renovating the main referral hospital in Mbabane, the capital, and a special facility for treating patients with drug-resistant tuberculosis (TB) opened in January, although it is still operating at a fraction of its capacity.



Despite staffing problems, the roll-out of HIV/AIDS testing and treatment management from hospitals, which are usually located in urban centres, to local clinics has been proceeding. The number of people on ARV medication increased from about 27,000 towards the end of 2008 to about 32,000 at present.



An estimated 60,000 Swazis are in need of treatment, but Sophia Mukasa Monico, the UNAIDS country coordinator, is confident that Swaziland will reach the universal access target of having 80 percent of people in need of ARVs on the drugs by 2010.



Keeping people on treatment presents perhaps the most serious challenge for Swaziland where about 30 percent of patients drop out of treatment during their first year on medication, according to the National Emergency Response Committee on HIV/AIDS (NERCHA), which coordinates Swaziland's HIV/AIDS response.



Treatment barriers



Poverty is the biggest barrier. Bringing treatment to patients helps reduce their transport costs, but some can scarcely afford enough food to take with their medication. "People can't take pills every day when they don't have food every day," Dlamini pointed out.









''People can't take pills every day when they don't have food every day''

Gcina Gwebu is an adherence officer working out of the Good Shepherd Hospital in Siteki, the main referral facility in the Lubombo Region in eastern Swaziland. His job is to follow up on patients who have failed to come to the hospital for drug refills.



Today he is at the homestead of a young pregnant woman who has defaulted on her ARV treatment. "When I saw her three weeks ago, she said she wasn't taking her drugs because she didn't have food to take with them," he told IRIN/PlusNews. "They're poor people."



Gwebu encouraged the woman to come to the hospital to pick up some corn-soya food supplement donated by the World Food Programme and restart her treatment. According to the woman's sister-in-law, she followed his advice, but on the day she came to the hospital there was no corn-soya. She died a few days later.



Many patients start treatment too late to benefit from the drugs, partly because of stigma, but also because of persistent beliefs in the power of traditional medicine and faith healing, said Mukasa Monico of UNAIDS. "By the time they realize that doesn't work, they've wasted time."



Swaziland has no programme for providing HIV and AIDS education to traditional and faith healers, many of whom discourage people from taking ARVs.



A young epidemic



Perhaps the most worrying news for those tasked with running the treatment programme was the publication in March of new government figures suggesting that Swaziland's HIV epidemic, already the most severe in the world, has not yet peaked.



An antenatal survey found that the percentage of pregnant women infected with HIV had climbed from 39 percent in 2006 to 42 percent in 2008.



Mukasa Monico pointed out that Swaziland's epidemic was "still young" compared to countries like Uganda, where prevalence peaked in the early 1990s, but the need for more effective HIV prevention is clearly urgent.



Antoinette Malima, a gender specialist at the United Nations Population Fund (UNFPA), commented that awareness-raising and condom distribution were of limited use in the context of high levels of poverty, which drove many women into sexual relationships for economic reasons.



"People know [about HIV risk], but they're not taking the precautions," she said. "A woman who has seven children to feed may not be worried about contracting HIV, but about getting food on the table."



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