Executive Summary

The world’s highest HIV prevalence and the increasing number of deaths due to AIDS is having unprecedented impact on Swaziland. Worryingly, with a generation of orphans and rapidly escalating poverty, this desperate situation is being accepted as ‘normal’. HIV/AIDS in Swaziland has been characterized by a slow onset of impacts that have failed to command an emergency response. With insufficient resource allocation and lack of capacity, slow onset events can become emergencies.  The absence of an agreed definition of “disaster” or “emergency” has helped to sustain this characterization. The nature of these terms is changing. The case of Swaziland emphasizes that they can be long-term, complex, widespread events that evolve over years.

      Swaziland is experiencing a generalized epidemic. National sero-sentinel surveillance prevalence increased from 3.9% in 1992 to 42.6% in 2004 (MOHSW, 2006). HIV prevalence is estimated at 19% among the entire population and 26% among productive adults (CSO, 2007). Currently, there are around 220,000 people living with HIV. At similar prevalence rates, this would equate to 56 million and 92 million infected individuals in the USA and EU respectively. Prevalence is similar in rural and urban areas, and all districts. Unless the trajectory changes, AIDS may claim the lives of two thirds of all 15 year olds. (UNAIDS, 2000)

     HIV/AIDS is different from past diseases. Previous epidemics were short-term and worked their way through society or were treated and eliminated. HIV/AIDS is a long-term event. Rising HIV prevalence predates intensified impact. The multidimensional impact of infections will last generations. Negative effects on families become embedded within Swazi society, altering the future development path of the country. Although dramatic, the estimates cited in this paper are conservative. Effective interventions will require an emergency response aimed at building capacity for long-term programmes founded on the realities driving Swaziland’s epidemic.  

     HIV/AIDS is permanently altering the structure of Swazi society. By 2025 there will be a thinning of the older age groups and the very young. Deaths among productive age groups are increasing the dependency ratio, constraining coping mechanisms and economic growth. Life expectancy fell from 60 years in 1997 to 31.3 years in 2004 - the worlds lowest. Mortality has risen significantly across the entire population over the past fifteen years. Infant mortality increased from 79 per 1 000 births in 1992 to 108 in 2004. Maternal mortality has increased from 230 per 100,000 births in 2000 to 370 in 2004. The crude death rate has doubled from 11 deaths per 1 000 people in the early 1990’s to 21.2 in 2004. Recent analysis show deaths rates in all regions in Swaziland now exceed emergency thresholds.