HIV PROGRAMMING in ESWATINI Design and Layout

Geographic and Programmatic Scoping for Adolescent Girls and Young Women HIV PROGRAMMING IN ESWATINI Design and layout: www.itldesign.co.za

Geographic and Programmatic Scoping for Adolescent Girls and Young Women HIV PROGRAMMING IN ESWATINI Acknowledgments

Acknowledgements

I would like to express my gratitude to UNICEF staff, especially Leonard Kamugisha, to the Global Fund, specifically Alexandra Plowright, and to Nqobile Tsabedze, Nomathemba, Lungile Tshabalala, and Lungile Nkambule at CANGO for their guidance and support on the development of the Consolidated Report. An appreciation is also extended to the key informants and focus group participants who made time to discuss areas of interest to the scoping exercise. The consultative meetings throughout the document development phase set a good foundation for the geographic and programmatic scoping for adolescent girls and young women, HIV programming in the Kingdom of Eswatini.

Lastly, I would like to thank the data collectors who collected data in Mahlangatja, Mhlume and SomntongoTinkhundla.

Documentation by:

Dr. Nyasha Madzingira Independent Consultant Mobile: +263-773061807 +263-712203745 Skype: dr.nyasha Email: [email protected] Table of Contents CONTENTS

Foreword vii

Abbreviations and Acronyms vii

A. BACKGROUND AND CONTEXT 1

1. Introduction 1 1.1 Purpose 1 1.2 The CANGO Programme 1 1.3 Methodology 3 1.4 Limitations to the Scoping Exercise 4 2. Global and Subregional HIV Situation 5 3. Global, Regional- and Country-Level Policy Environment 7 3.1 Commitments at Global Level 7 3.2 Continental and Regional Policies and Strategies 9 3.3 Eswatini HIV and AIDS Policy Environment 11

B. NATIONAL GEOGRAPHIC AND | PROGRAMMATIC SCOPING OF AGYW 14

4. Statistical Snapshot 14 5. Programme Results 16 6. Intervention Mapping 16 7. Coordination 23 8. Key Global Investments 24

v C. GEOGRAPHIC AND PROGRAMMATIC SCOPING OF AGYW IN 3 TINKHUNDLA 26

9. Statistical Snapshot of the Three Tinkhundla 26 10. Socioeconomic Environment 27 10.1 Living Arrangements for AGYW 27 10.2 HIV and AIDS 28 10.3 SRH and HIV and AIDS Services 31 10.4 Education 34 10.5 Gender-based Violence Response 36 10.6 Civil Society Organizations 37 11. Economic Empowerment Programmes for AGYW 39 12. Community Structures and Systems for HIV Prevention among AGYW 41

D. CHALLENGES 42

13. Challenges/Gaps 42 13.1 Overall 42 13.2 Constraints Faced by AGYW 43 13.3 Challenges Faced by ABYM 44

E. RECOMMENDATIONS 45

ANNEXES 47 Annex 1. Documents Reviewed 47 Annex 2: List of Key Respondents 50 Annex 3: Mahlangatja Clinic Checklist 52

vi BACKGROUND AND CONTEXT A

ForewordAbbreviations and Acronyms ABYM Adolescent boys and young men AG Adolescent girls AGYW Adolescent girls and young women AIDS acquired immunodeficiency syndrome ART antiretroviral treatment ASRH adolescent sexual and reproductive health AU Africa Union Commission BSRCS Baphalali Eswatini Red Cross Society CANGO Coordinating Assembly of Non-governmental Organizations CBO Community-based Organization CDC Centers for Disease Control and Prevention CHAPS Centre for HIV and AIDS Prevention Studies CHIPS Children’s Intervention in Swaziland COMM ART Community-centred models of ART COP Country Operational Plan CSE Comprehensive sexuality education CSO Central Statistical Office CSTL Care and support for teaching and learning DHS Demographic and Health Survey DREAMS Determined, Resilient, Empowered, AIDS-free, Mentored and Safe EGPAF Elizabeth Glaser Pediatric AIDS Foundation ESA Eastern and southern Africa ESAR Eastern and southern Africa region FGDs Focus group discussions FLAS Family Life Association of Eswatini GBV Gender-based violence GF Global Fund GKoE Government of the Kingdom of Eswatini HIV human immunodeficiency virus HSS Health system strengthening HTC HIV testing and counselling HTS HIV testing services IEC Information, education and communication IPPF International Planned Parenthood Federation LSE Life-skills education MDR-TB Multi-drug-resistant tuberculosis MICS Multiple Indicator Cluster Survey MITC Manzini Industrial Training Centre MOH Ministry of Health MSF Médecins Sans Frontières MSM Men having sex with men

vii NaHSAR National HIV Semi- Annual Review NATICC Nhlangano AIDS Training Information and Counselling Centre NERCHA National Emergency Response Council on HIV and AIDS NFM 1 New Funding Model 1 Cycle from 2014 to 2016 NGO Non-governmental organization NSF National Strategic Framework for HIV and AIDS OVC Orphans and vulnerable children PEP Post-exposure prophylaxis PEPFAR President’s Emergency Plan for AIDS Relief PLHIV People living with HIV PMTCT Prevention of mother-to-child transmission PrEP Pre-exposure prophylaxis PSI Population Services International RA Research Assistant REC Research Ethics Committee RSSC Royal Swaziland Sugar Company SADC Southern Africa Development Community SANU Southern Africa Nazarene University SBCC Social behaviour change communication SGBV Sexual and gender-based violence SHIMS 2 Eswatini HIV Incidence Measurement Survey 2 SMS Short message service SNAP Eswatini National AIDS Programme SRH Sexual and reproductive health SRHR Sexual and reproductive health and rights STI Sexually transmitted infections SWAGAA Eswatini Action Group Against Abuse TA Technical assistance TB Tuberculosis TFFC Taiwan Fund for Children TOR Terms of Reference UN United Nations UNAIDS Joint United Nations Programme on HIV and AIDS UNESCO United Nations Educational, Scientific and Cultural Organization UNFPA United Nations Population Fund UNGASS United Nations General Assembly Special Session UNICEF United Nations Children’s Fund USAID United States Agency for International Development VH Viral hepatitis VLS Viral load suppression VMMC Voluntary medical male circumcision WFP World Food Programme WHO World Health Organization YM young men YW young women viii BACKGROUND AND CONTEXT A.

1. Introduction 1.1 Purpose

UNICEF Eswatini Country Office commissioned an assignment entitled ‘Geographic and Programmatic Scoping for Adolescent Girls and Young Women HIV Programming in Three Constituencies/Tinkhundla in Eswatini’. The assignment was divided into two main areas of work, the first being a comprehensive literature review to be complemented by key informant interviews on the status of HIV and adolescent girls and young women with respect to: a) policy; b) funding and; c) programming in the country.

The second was the scoping of three constituencies (namely Mahlangatja in Manzini Region; Mhlume in Lubombo Region and Somthongo in Shiselweni Region) in support to CANGO (Coordinating Assembly of NGOs) which is a Global Fund Principal Recipient and will be initiating a programme for adolescent girls and young women (AGYW) in the three Tinkhundla from October 2018. The scoping addressed the following objectives:

i. Determine HIV, health, education, social services, gender-based violence (GBV) response, justice/police, community-based organizations based in the relevant geographical areas and their scope of work; ii. Assess existence of income-generating projects/initiatives involving AGYW; iii. Determine social/economic engagements of AGYWs (what occupies their time); and iv. Assess the extent to which there is a community support system that enables AGYW to access HIV and sexual and reproductive health- (SRH) related services.

This Consolidated Report is the deliverable for the both parts of the assignment.

1.2 The CANGO Programme

CANGO has been receiving funding from the Global Fund since 2016 as Principal Recipient representing civil society. This funding is mainly for an HIV prevention programme and is further distributed to sub-recipients who directly implement the programmes while CANGOs role is mainly around the management of the grant and the provision of technical support and guidance. A community programme designed for out-of-school youth is offered in 20 constituencies. The overall goal of the programme is to halt the spread of HIV and reverse its impact in Eswatini society.

A special programme for AGYW aged 10–24 years is implemented in three high density, low income constituencies namely; Somntongo, Mahlangatja and Mhlume from the Shiselweni, Manzini and Lubombo regions, respectively. This

1 programme has two layers, the first layer is the Stepping Stone sessions which provide HIV prevention education and distribution of condoms. These sessions also act as basis to identify beneficiaries who qualify and are willing to be a part of the second layer, namely economic strengthening and education support. Through the economic strengthening, beneficiaries are taken through the WORTH Programme which is believed to provide economic freedom to the AGYWs, while the education support comes in the form of secondary education subsidies which are paid directly to the school. The expected immediate outcomes for these programmes are improved knowledge around HIV Testing Services (HTS) and increased service uptake for HTS and Sexual and Reproductive Health (SRH) while the long-term objective is the reduction of new HIV infections among AGYW by 2022.

Two sub-recipients (World Vision and Young Heroes) are responsible for the implementation of this programme and the target is to support 500 individuals with the education subsidies throughout the three years (2018−2021), 4000 individuals per year with the Stepping Stone sessions and 420 individuals/members for the WORTH groups. Other innovations include activities i which provide HTS services for youth. A similar programme for the New Funding Model 1 Cycle from 2014 to 2016 (NFM 1), which has been under implementation between 2016 and 2018, provided only one layer, which is the Stepping Stone session in 20 constituencies.

The CANGO programme contributes to the national response and is aligned to the country’s aims of reducing both new infections and mortality substantially. As indicated in the National Strategic Framework for HIV and AIDS (NSF) 2018−2022 this will be achieved by super-fast tracking the response in the next five years and will meet the following impact targets by 2022:1

i. Reduction of HIV incidence among adults by 90 per cent from a baseline of 2010; ii. Reduction of incidence among 15−24 year-olds by 90 per cent from a baseline of 2010; iii. Elimination of new HIV infections among infants to less than 0.05 per cent; and iv. Reduction of AIDS deaths by 50 per cent.

The programme is expected to contribute to regional and global targets, including those in the Eastern and Southern Africa (ESA) Ministerial Commitment, UNAIDS Fast-Track Strategy, the WHO End TB Strategy, the 2016 Political Declaration on HIV and AIDS and the Sustainable Development Goals:2

i. Achieve 90-90-90 targets for HIV and 90-(90)-90 targets for TB by 2020; ii. Fewer than 200,000 new HIV infections and an 80 per cent reduction in TB incidence by 2030; iii. Reduce early and unintended pregnancies among young people by 75 per cent by 2020; iv. Expand community-led service delivery to cover at least 30 per cent of all service delivery by 2030; and v. End HIV and TB as public health threats by 2030.

1 Government of Eswatini. 2018. National MultiSectoral HIV and AIDS Strategic Framework 2018−2022. 2 Eswatini TB-HIV Funding Request-Final 2 BACKGROUND AND CONTEXT A

1.3 Methodology

The overall approach to data collection was a review of literature, key informant interviews and consultative meetings as described below.

i. Literature review A review of literature was undertaken focused on global and regional policy and strategy documents, national policies and strategies, and development partners’ documents on technical, programmatic and funding support provided (see Section 11 − list of documents reviewed).

ii. In-depth interviews Twelve one-on-one in-depth interviews were carried out with staff from the Ministry of Health, the Ministry of Education, UNESCO, the Department of Social Welfare, National Emergency Response Council on HIV and AIDS (NERCHA), Central Statistical Office (CSO), implementing partners, UN funding partners, and the President’s Emergency Plan for AIDS Relief (PEPFAR) through USAID (see annex 2). The UNICEF AGYW Stay Free tool was adapted and utilised for the collection of information, some of which is included in this report.

Twenty one-on-one in-depth interviews were carried out with key informants in Mahlangatja, Mhlume and Somntongo. These include the Tinkhundla Secretary, health service providers, teachers, community leaders, church leaders, Rural Health Motivators, the police and Community-based Organizations (CBOs). The tool used was a key informant interview guide customised to each key informant.

iii. Consultative meetings An inception meeting was held with UNICEF, the Global Fund and CANGO to clarify the purpose and objectives of the assignment and agree on a workplan for its execution. Consultative meetings continued throughout the process of literature review, key informant interviews and the scoping for consensus-building and adding value to the final deliverables. A stakeholder validation meeting is planned before finalisation of the Report.

iv. Focus Group Discussions Twenty-two Focus Group Discussions (FGDs) were conducted with groups of adolescents and young people (in and out-of-school) from the three Tinkhundla. Separate focus group discussions were convened with boys and girls, and young women and young men as indicated in table 1 below. Two FGDs were also conducted with community members (men and women). An FGD guide was used to structure the discussions. The respondents were purposively identified in both rural and urban settings.

Table 1: Focus Group Discussions

FOCUS GROUP DISCUSSION IN OUT-OF- SCHOOL SCHOOL Adolescent girls 10-14 years 3 - Adolescent girls 15-19 years 5 - Young women 20-24 years 2 4 Young men 20-24 years 4 3 Community members/Parents (2 FGDs)

WFGD with community members at Mgidzangcunu Community, Mhlume Inkhundla

3 i. Check list As part of the scoping exercise, two standard checklists were developed and used for the collection of data in the Tinkhundla on (a) number of schools and (b) number of clinics/hospitals and the services they offer to adolescent girls and young women. One checklist completed for Mahlangatja clinic is attached in annex 2.

ii. Recruitment and training of data collectors Ten Data Collectors carried out fieldwork in Mahlangatja, Mhlume and Somntongo Tinkhundla. The Data Collectors were trained for two days (Tuesday 26 and Wednesday 27 September 2018) on the tools for data collection, how to administer them and on the respondents to be targeted. One of the ten Data Collectors was selected as Team Leader. The team of Data Collectors collected data from the three Tinkhundla, one after the other, for two days per Inkhundla, totalling six days of fieldwork.

iii. Method of data analysis The Data Collection team held daily de-briefing meetings to identify common themes from the information collected. The team transcribed the FGDs and the key informant interviews and used the output to develop an Inkhundla Report. The Data Collectors used a template to summarise Tinkhundla information under selected themes in line with the main report structure. Data triangulation was used in analysing both secondary and primary data culminating in the development of the Scoping Report.

iv. Ethical considerations for the scoping exercise CANGO fulfilled the requirements of the Research Ethics Committee (REC) by lodging the scoping exercise proposal before the committee for its determination. A waiver was granted to carry out the assignment. At field level, ethical issues of confidentiality and volunteering to participate in the scoping exercise were observed. Participants were briefed on the purpose of the scoping exercise and asked if they would volunteer to participate as either key informants, or focus group discussion participants and have photos captured during the process. They were assured that there would be no prejudice to those who opted out of the exercise. Those who volunteered to participate in the data collection were asked to sign a consent form.

1.4 Limitations to the Scoping Exercise

Three issues can be cited as limitations to the study:

f AGYW data is not readily available as most data is not disaggregated by sex, for example the AGYW Dashboard managed by the Ministry of Health; and programme funding information does not provide specific funds for AGYW programming. f Qualitative data collection and analysis would have benefited from primary quantitative data to answer questions such as AGYW living arrangements and how many are out-of-school. Nevertheless, the report relied on secondary data where possible to fill the identified gaps. The information will further benefit from the Population and Housing Census Final Results 2017 when available. f Discussing sex and sex-related issues are not easy topics especially when talking to a stranger. Some of the adolescents and young people interviewed in the scoping exercise shied away from the discussion, especially those in the 10−14 year age group. However, the trained Data Collectors were able to involve everyone in the discussions.

4 BACKGROUND AND CONTEXT A

2. Global and Subregional HIV Situation

According to UNAIDS 2018, 36.9 million people were living with HIV in 2017 globally (35.1 million adults; 18.2 million women aged 15 years and above; and 1.8 million children aged below 15 years). The annual number of global deaths from AIDS-related illness among people living with HIV (all ages) has declined from a peak of 1.9 million in 2004 to 940,000 in 2017. Since 2010, AIDS-related mortality has declined by 34 per cent. The global decline in deaths from AIDS- related illness has largely been driven by progress in sub-Saharan Africa, particularly eastern and southern Africa, which is home to 53 per cent of the world’s people living with HIV. AIDS-related mortality declined by 42 per cent from 2010 to 2017 in eastern and southern Africa, reflecting the rapid pace of treatment scale-up in the region.3

The UNAIDS Report further noted that mortality reductions remain higher among women than men. This gender gap is particularly notable in sub-Saharan Africa, where 56 per cent of people living with HIV are women. Despite the higher disease burden among women, more men living with HIV are dying. In 2017, an estimated 300,000 men in sub- Saharan Africa died of AIDS-related illness compared to 270,000 women.4

The number of new HIV infections globally continued to decline in 2017. Modelled estimates show that new infections (all ages) declined from a peak of 3.4 million in 1996 to 1.8 million in 2017. As is the case with AIDS-related mortality, the reduction in new HIV infections between 2010 and 2017 was strongest in sub-Saharan Africa due to sharp reductions in eastern and southern Africa (30 per cent decline). Despite the decline, progress is far slower than is required to reach the 2020 milestone of less than 500,000 new infections. Women continue to account for a disproportionate percentage of new HIV infections among adults (aged 15 and older) in sub-Saharan Africa: they represented 59 per cent of the 980,000 new adult HIV infections in 2017.5

AIDS-related illnesses remain the leading cause of death among women of reproductive age (15–49 years) globally, and they are the second leading cause of death for young women aged 15–24 years in Africa. Many women are also excluded from prevention of mother-to-child transmission of HIV (PMTCT) programmes due to distances to health facilities, low quality of services, stigma and discrimination and lack of spousal/partner support, family or community support. This leads to more than 1,000 infants being born with HIV every day in sub-Saharan Africa.6 In the Eastern and Southern Africa Region, 93 per cent of the 940,000 pregnant women living with HIV received antiretroviral prophylaxis in 2017,7 while 62 per cent of children born of HIV positive women received their virological test within the first two months as compared to 23 per cent in 2009.8 Fifty-nine per cent of HIV positive children are receiving ART as of 2017.9 The region accounts for 90 per cent of new HIV infections in children in the world.10 Care and support to the children made vulnerable by HIV and AIDS are nowhere near adequate. In most countries in the region, only around 20 per cent or less of these children receive some sort of external support.11

3 UNAIDS Data 2018. 4 Ibid 5 Ibid 6 https://www.unicef.org/esaro/7310_Gender_and_PMTCT.html 7 UNAIDS. 2018. Global AIDS Update ”Miles to Go”. 8 UNICEF. 2018. Data – Infants HIV Testing 2017. 9 UNAIDS. 2018. Fact Sheet – Latest statistics on status of the epidemic. 10 UNICEF Eastern and Southern Africa (2015) Regional Analysis Report. 11 https://www.unicef.org/esaro/5482_HIV_AIDS.html

5 In Eastern and Southern Africa 2.7 million people aged 15−24 years live with HIV, which is more than half of all young people living with HIV globally.12 Although AIDS-related deaths in the ESAR among adolescents and young people have generally been decreasing, the mortality rate remains high among adolescent girls and young women and is increasing among adolescent boys and young men. In Eswatini and Lesotho, adolescent girls aged 15−17 years, have 4 times higher HIV prevalence than their male peers.13 Adolescents are also underserved by HIV services and have lower adherence to medical appointments.14 Treatment adherence presents a significant challenge for adolescents living with HIV whether they acquired it vertically or horizontally.15 Child marriage is also a widespread problem in many countries in east and southern Africa, and is also a serious violation of girls’ human rights. It denies them their right to health care, to education, to live in security and to choose when and whom they marry. Child marriage has dire consequences especially for girls.16 Violence against children is also an issue of concern in Eastern and Southern Africa, with research carried out by UNICEF and partners revealing a picture of widespread violence against girls and boys. Of the gender-based violence cases recorded under the National Surveillance System (2016) in Eswatini, 35 per cent were of emotional abuse, 31 per cent were physical abuse and 19 per cent were sexual abuse cases.17 A study in Tanzania found that nearly 3 in 10 women and 1 in 7 men experienced sexual violence as children.18

Studies carried out by UNICEF and Centers for Disease Control and Prevention in ESA showed that over 70 per cent of boys and girls reported severe beatings, with teachers and parents as primary perpetrators across most countries. Reporting of incidents of violence, however, is poor, with 50 per cent for girls and even fewer for boys. Of those who did report, less than half ever received services.19 A study on violence against children in Tanzania showed that 30 per cent of female respondents between the ages of 13 and 24 years who had lost one or both parents before reaching adulthood experienced sexual abuse as compared to 20 per cent of non-orphan respondents.20

12 https://www.unicef.org/esaro/5482_HIV_prevention.html 13 UNAIDS. 2015. UNAIDS Gap Report. 14 REPSSI. 2016. Resourcing Resilience; The Case of Social Protection for HIV Positive Children on ART in ESA. 15 RIATT-ESA. 2015. Intensify HIV Prevention and Treatment for Adolescents. 16 UNFPA ESARO website: http://esaro.unfpa.org/en/topics/child-marriage 17 Government of Eswatini. 2016. National Surveillance System on Violence in Eswatini. Annual Report for the year ended 2016. 18 https://www.unicef.org/esaro/5480_violence-against-children.html 19 UNICEF national population-based surveys in Eswatini, Kenya, Malawi, Tanzania and Zimbabwe. 20 Ibid. 6 BACKGROUND AND CONTEXT A

3. Global, Regional- and Country-Level Policy Environment

3.1 Commitments at Global Level

There are various commitments, conventions and strategies developed at global level aimed at ensuring the provision of services for children, adolescents and young people. These are detailed in: the Convention on the Rights of the Child; UNGASS Political Declaration on HIV and AIDS 2016; United Nations Sustainable Development Goals; UNAIDS 90-90-90 Strategy; Start Free, Stay Free, AIDS Free Framework; the WHO Global Health Strategies 2016−2021; and the Global Strategy For Women’s, Children’s and Adolescents’ Health (2016−2030).

The Convention on the Rights of the Child (1989)21 is an internationally binding human rights treaty signed by all UN member states (except the United States) which ensures the protection of children, adolescents and young people. Some of the rights that the convention highlights are non-discrimination, protection of rights, survival and development, ensuring the best interests of the child, access to health and health services, right to education, access to information and mass media, and protection from all forms of violence.

Under the United Nations Sustainable Development Goals 2030,22 five goals speak specifically to children, adolescents and young people in terms of universal health coverage; universal primary and secondary education; gender equality and empowerment; productive employment and decent work; and access to justice as highlighted in the goals below:

Goal 3: Ensure healthy lives and promote well-being for all at all ages;

Goal 4: Ensure inclusive and equitable quality education and promote life-long learning opportunities for all;

Goal 5: Achieve gender equality and empower all women and girls;

Goal 8: Promote sustained, inclusive and sustainable economic growth, full and productive employment and decent work for all; and

Goal 16: Promote peaceful and inclusive societies for sustainable development, provide access to justice for all and build effective, accountable and inclusive institutions at all levels.

The UNGASS Political Declaration on HIV and AIDS 201623 on the Fast Track to Accelerating the response to HIV and to Ending the AIDS Epidemic by 2030 further recognizes the need for gender equality and equity; access to services; and promotion of laws that fight against stigma and discrimination. These are detailed in the six points below adapted from the Declaration:

i. Ensuring access to testing and treatment in the fight against HIV and AIDS; ii. Pursuing transformative AIDS responses to contribute to gender equality and the empowerment of all women and girls;

21 United Nations, 1989. Convention on the Rights of the Child Adopted and opened for signature, ratification and accession by General Assembly resolution 44/25 of 20 November 1989; entry into force 2 September 1990, in accordance with article 49. 22 United Nations, 2015. Sustainable Development Goals, available at: https://sustainabledevelopment.un.org/?menu=1300 23 UNGASS, 2016. Political Declaration on HIV and AIDS: On the Fast Track to Accelerating the Fight against HIV and to Ending the AIDS Epidemic by 2030.

7 iii. Ensuring access to high-quality HIV services, commodities and prevention while expanding coverage, diversifying approaches and intensifying efforts to fight HIV and end the AIDS epidemic; iv. Promoting laws, policies and practices to enable access to services and end HIV-related stigma and discrimination; v. Engaging and supporting people living with, at risk of and affected by HIV as well as other relevant stakeholders in the AIDS response; and vi. Leveraging regional leadership and institutions is essential to more effective AIDS responses.

The UN 90-90-90 Strategy24 aims at countries achieving the three 90s and ensuring that no one is left behind where 90 per cent of all people living with HIV know their HIV status; 90 per cent of all people with diagnosed HIV infection receive sustained antiretroviral therapy; and 90 per cent of all people receiving antiretroviral therapy have viral suppression by 2020.

The Start Free, Stay Free, AIDS Free Framework,25 sponsored by UNAIDS, PEPFAR, World Health Organization (WHO), UNICEF and the Elizabeth Glaser Paediatric AIDS Foundation (EGPAF), built on the UNGASS Political Declaration and also the Global Plan for PMTCT and included critical targets related to children and adolescents living with HIV. Countries are to contribute to the achievement of the following global targets:

Start Free: • Eliminate new HIV infections among children (aged 0–14 years) by reducing the number of children newly infected annually to less than 40,000 by 2018 and 20,000 by 2020. • Reach and sustain 95 per cent of pregnant women living with HIV with lifelong HIV treatment by 2018. Stay Free: • Reduce the number of new HIV infections among adolescents and young women (aged 10–24 years) to less than 100,000 by 2020. • Provide voluntary medical circumcision for HIV prevention to 25 million additional men by 2020, with a focus on young men (aged 10–29 years). AIDS Free: • Provide 1.6 million children (aged 0–14 years) and 1.2 million adolescents (aged 15–19 years) living with HIV with antiretroviral therapy by 2018. • Provide 1.4 million children (aged 0–14 years) and 1 million adolescents (aged 15–19 years) with HIV treatment by 2020.

WHO Global Health Strategies 2016-202126 addresses three major public health issues: HIV, viral hepatitis (VH) and sexually transmitted infections (STI). The strategy states the need to prioritize combination HIV prevention to adolescents, girls and young women, and male sexual partners, particularly in high-burden settings in sub-Saharan Africa, using interventions that aim to reduce both vulnerability and risk behaviours, including gender-based and sexual violence and sexual risk behaviour associated with alcohol and other drug use. Secondly, it encourages the provision of guidance on combination HIV prevention, rapidly integrating new, evidence-based health sector interventions into HIV prevention packages for different epidemic contexts, with particular attention to female and male adolescents, girls, women and key populations (including young key populations).

24 UN. 2014. 90-90-90 targets 25 http://www.unaids.org/sites/default/files/media_asset/Stay_free_vision_mission_En.pdf 26 WHO. 2015. Global Health Sector Strategies on HIV, Viral Hepatitis and Sexually Transmitted Infections (STIs) 2016-2021. Briefing Note: October 2015.

8 BACKGROUND AND CONTEXT A

The Global Strategy For Women’s, Children’s and Adolescents’ Health (2016−2030)27 takes a life-course approach that aims for the highest attainable standards of health and well-being − physical, mental and social − at every age, cognisant that a person’s health at each stage of life affects health at other stages and also has cumulative effects for the next generation. The Global Strategy focuses on survival, thriving and transformation:

• Survive: Ending preventable deaths

• Thrive: Ensuring health and well-being

• Transform: Expanding enabling environments.

3.2 Continental and Regional Policies and Strategies

Three policy documents at the African Union Commission (AU) level speak to the provision of comprehensive HIV and AIDS services to adolescents and young women. These are the AU Agenda 2063, the AU Campaign to End Child Marriages and the Catalytic Framework to End AIDS, TB and Eliminate Malaria. The AU Agenda 206328 highlights child health and rights and provision of comprehensive services throughout the lifecycle as espoused in Aspiration 6: An Africa whose development is people-driven, relying on the potential of African people, especially its women and youth, and caring for children. The AU Campaign to End Child Marriage in Africa: Call to Action 201329calls on governments to end the harmful practice of child, early and forced marriage, while the Catalytic Framework to end AIDS, TB and Eliminate Malaria in Africa (African Union, 2016)30, 31 highlights issues of social protection especially for children, adolescents and young people; generation and use of evidence for policy and programme interventions; evidence driven advocacy; and capacity building.

The revised Maputo Plan of Action 2016−203032 provides a framework to achieve universal access to comprehensive sexual and reproductive health rights and services in the post-2015 period. It was developed by the African Union Commission and follows on from the Maputo Plan of Action 2007-2015. The ultimate goal of the Plan of Action is to guide the effective implementation of the continental policy framework on SRHR in order to end preventable maternal, newborn, child and adolescent deaths, expand contraceptive use, reduce levels of unsafe abortion, end child marriage, eradicate harmful traditional practices including female genital mutilation and prevent gender-based violence and ensure access of adolescents and youth to SRH by 2030 in all countries in Africa.

27 United Nations. 2015. The Global Strategy For Women’s, Children’s And Adolescents’ Health (2016-2030). 28 African Union Commission. 2015. Agenda 2063: The Africa We Want. 29 African Union Commission. 2013. Campaign To End Child Marriage In Africa: Call To Action 2013. 30 African Union Commission. 2016. Catalytic Framework to End AIDS, TB and Eliminate Malaria In Africa By 2030. Working Group of the Specialised Technical Committee on Health, Population and Drug Control, Experts Meeting 25 to 26 April 2016, Addis Ababa; Ministers of Health Meeting Geneva, 21 May 2016. 31 African Union Targets and Milestones to End AIDS, TB and Malaria by 2030. 32 The African Union Commission. Maputo Plan Of Action 2016-2030 For The Operationalisation Of The Continental Policy Framework For Sexual And Reproductive Health And Rights. 9 The Ministerial Commitment of the Eastern and Southern Africa (ESA) Meeting in 201333 ensures that all young people have access to high quality, comprehensive life skills-based HIV and sexuality education, and to appropriate youth- friendly health services. Below are some of the specific commitments:

f Work together on a common agenda for all adolescents and young people to deliver comprehensive sexuality education (CSE) and youth-friendly SRH services that will strengthen our national responses to the HIV epidemic and reduce new HIV/STI infections, early and unintended pregnancy and strengthen care and support, particularly for those living with HIV. f Review − and where necessary amend − existing laws and policies on age of consent, child protection and teacher codes of conduct to improve independent access to sexual and reproductive health services for adolescents and young people and also protect children. f Make an AIDS-free future a reality by investing in effective, combination prevention strategies. f Ensure that the design and delivery of CSE and SRH programmes include ample participation by communities and families. f Integrate and scale up youth-friendly HIV and SRH services. f Ensure that health services are youth-friendly, non-judgemental, and confidential and reach adolescents and young people. f Strengthen gender equality and rights within education and health services.

At the regional level of the Southern Africa Development Community (SADC), the SADC Health Protocol (1999)34 addresses health needs for young people under Article 3 with one of its main objectives (g) to develop common strategies to address the health needs of women, children and other vulnerable groups. Article 17 alludes to the provision of appropriate childhood and adolescent health services essential for the critical foundation for growth and development of children, committing state parties to:

f Co-operate in improving the health status of children and adolescents; f Develop and formulate coherent and standardised policies and set out targets with regard to child and adolescent health; and f Encourage adolescents to delay engaging in early sexual activity which may result in unwanted teenage pregnancies.

The Maseru Declaration on the Fight against HIV/AIDS in the SADC region (2003)35 provides a framework for youths and children in a number of its provisions. The declaration placed emphasis on strengthening communities and families to prevent and mitigate the impact of HIV and AIDS on children and youth. In line with the Maseru Declaration, the goal of SADC interventions to combat the HIV and AIDS pandemic to decrease the number of individuals and families in the region infected and affected by HIV and AIDS so that they are no longer a threat to public health and to socioeconomic development as highlighted in the Regional Indicative Strategic Development Plan.36 The intervention areas include HIV prevention strategies that address emerging issues and special populations such as young women and girls and mobile populations; improving access to treatment for children and adolescents; improving quality of HIV treatment in terms of patient monitoring, adherence management, efficacy of commodities and enhancing and

33 UNAIDS. 2013. Ministerial Commitment on comprehensive sexuality education and sexual and reproductive health services for adolescents and young people in Eastern and Southern African (ESA). 6th - 7th December 2013 Held at the Westin, Cape town, South Africa. 34 SADC, 1999. SADC Protocol on Health. 35 SADC, 2003. Maseru Declaration on the Fight against HIV/AIDS in the SADC Region (2003). 36 SADC, 2015. Regional Indicative Strategic Development Plan 2015−2020; SADC Declaration on Youth Development and Empowerment.

10 BACKGROUND AND CONTEXT A

sustaining treatment coverage; sustainable financing; domestication and monitoring of policies and frameworks; and monitoring and evaluation of regional and global commitments.

The SADC Integrated HIV, SRH, TB and Malaria Strategy and Business Plan 2016−2037 is in place to ensure accelerated effective delivery of quality and comprehensive health and related services for all people, irrespective of age, sexual orientation, marital status and gender. The document specifically mentions that SADC should ensure that children, adolescents, youth, people with disability and key populations for all programmes access HIV, SRH, TB and malaria services. A dedicated section on adolescence and sexual health specifies the need for strategies to: f Scale up access and quality of comprehensive sexuality education; f Increase access to sexual and reproductive youth services; and f Improve access to family planning services.

Other critical policy documents are the SADC 1998 Addendum on the Prevention and Eradication of Violence against Women and Children; the Minimum Package for HIV and SRH Integration in the SADC Region (2015)38 and the Policy Framework for Population Mobility and Communicable Diseases in the SADC Region (2009).39

3.3 Eswatini HIV and AIDS Policy Environment

Eswatini has developed some policies and strategies to guide the provision of comprehensive HIV and AIDS and health services for children, adolescents and young people in the country. The vision for the country in the HIV response is to end AIDS by 2022. Guided by the National MultiSectoral HIV and AIDS Strategic Framework (NSF) 2018−2022, the country aims to reduce significantly both new infections and mortality through super-fast tracking the response in the next five years. Key programmes to achieve this goal are: HIV primary prevention, treatment, care and support; social protection and reduction of vulnerabilities, HIV response management, sustainable financing and strategic information and research. The following impact targets are to be achieved by 2022: f Reduction of HIV incidence among adults by 90 per cent from a baseline of 2010; f Reduction of incidence among 15−24 years old by 90 per cent from a baseline of 2010; f Elimination of new HIV infections among infants to less than 0.05 per cent; and f Reduction of AIDS deaths by 50 per cent.

The NSF is complemented by new policies and strategies developed between 2016 and 2018 that include the roll-out of the test-and-start programme (October 2016), differentiated care (“CommART”) (June 2016), routine viral load testing (April 2017), shorter MDR-TB regimen (January 2017), the new national strategy to end violence (2017−2022), the new MDR-TB guidelines, the country’s launch of the “Three Frees” Framework (May 2017), and the national frameworks on HIV self-testing as well as pre-exposure prophylaxis (PrEP).

In July 2018, the Sexual Offences and Domestic Violence Bill received Royal Assent from His Majesty King Mswati III to be enacted into law as the Sexual Offences and Domestic Violence Act, 2018. The goal of the Act is to promote the protection of society’s most vulnerable, including women and children. The Act gives effect to certain rights enshrined in the Constitution of Eswatini of 2005; strengthens and consolidates certain common law and statutory provisions so as to adequately provide for dealing successfully with sexual offences and domestic violence and to provide adequate

37 SADC, 2017. SADC Integrated HIV, SRH, TB and Malaria Strategy and Business Plan, 2016-20. 38 SADC (2015) Minimum Package for HIV and SRH Integration in the SADC Region. 39 SADC (2009) Policy Framework for Population Mobility and Communicable Diseases in the SADC Region.

11 protection to complainants; aims to end impunity of perpetrators by imposing terms of imprisonment on convicted persons that are proportionate to the crimes committed; and it gives effect to several international legal instruments that the country has ratified and accented to.

The National Health Sector Strategic Plan II (2014−2018) was designed around the need to attain Universal Health Coverage with the health and related services. The SRH interventions under the strategy are aimed at the delay of sexual debut using a cultural-rooted approach; sharing of correct information for better understanding of HIV amongst adolescents and youth; strengthen capacity of service providers on tailored SRH and family health services at all levels; and promoting youth and adolescent comprehensive sexuality and family health services.40

The goal of the revised National Education and Training Sector Policy (2018)41 is the provision of an equitable and inclusive education and training system that affords all learners access to free and compulsory basic education and senior secondary education of high quality, followed by the opportunity to continue with life-long education and training so enhancing their personal development and contributing to Eswatini’s cultural development, socioeconomic growth and global competiveness.

The National Policy on Sexual and Reproductive Health of 2013 is a guide for the implementation of well-coordinated and integrated sexual and reproductive health and rights programmes for the attainment of the highest level of health and well-being for all people of Eswatini.42 The Framework notes that comprehensive sexuality education and information, and integrated SRH and HIV services shall be provided to children, adolescents and young people at all levels of the health care delivery systems and other relevant settings according to their age and need; and that the Ministry of Health shall provide an enabling environment and resources to provide adolescent sexual and reproductive health (ASRH) services and quality family planning information and care shall be provided to all women and men of reproductive age.43,44

The overall goal of the National HIV Prevention Policy 201245 is to promote an enabling environment for the scaling up of biomedical and non-biomedical HIV prevention interventions to reduce the HIV incidence in Eswatini. The Policy states that SRH education shall be integrated into HIV and provided through life skills education programmes at all levels of formal and non-formal education settings as well as through community-based structures; for out-of- school youth, HIV prevention information, sexual and life skills education shall be made available through various interpersonal and mass media interventions that are tailor-made for the youth; all SRH services and commodities shall be made accessible to all individuals and provided in accordance with the national guiding protocols; dual protection against STIs, HIV and unintended pregnancy shall be emphasized; and SRH services shall be provided in line with the adolescent SRH policy and shall focus on the prevention of early pregnancies, STIs and HIV.46,47 The policy addresses structural and cultural factors that increase vulnerability to HIV infection to foster sustainable changes in both individual behaviours and social norms.

The Children’s Protection and Welfare Act 201248 provides for the right of a child to access health care services from the age of 12 years, and the age of consent for HIV testing is 12 years as stipulated in the HIV prevention policy.

40 Ministry of Health, 2014. The Second National Health Sector Strategic Plan 2014−2018. 41 The Government of the Kingdom of Eswatini, 2018. National Education and Training Sector Policy. 42 Ministry of Health, 2013. National Policy on Sexual and Reproductive Health. 43 Ibid. 44 Eswatini’s TB/HIV Funding Request to the Global Fund: Matching Funds, 28 August 2017. Final. 45 Government of the Kingdom of Eswatini, 2012. National HIV Prevention Policy. 46 Ibid. 47 Eswatini’s TB/HIV Funding Request to the Global Fund: Matching Funds, 28 August 2017. Final. 48 Government of the Kingdom of Eswatini, 2012. Children’s Protection and Welfare Act 2012 (Act No. 6 of 2012). 12 BACKGROUND AND CONTEXT A

Further, the National Youth Policy 200949 calls for improved access to HIV/AIDS treatment for youth, the integration of Life Skills Education (which includes sexuality education) curricula into all institutions, the promotion of school- and community-based health clubs, and scale-up of SRH services targeting all youth, to reduce STI prevalence and unplanned pregnancies.

The National Policy on HIV and AIDS 200150 noted the need to increase the capacity of women, youth and other vulnerable or disadvantaged groups such as disabled persons, sex workers, children living on the streets, and others to protect themselves against HIV and AIDS and other sexually transmitted infections.

Eswatini has policies in place that are aligned to regional, continental and global commitments that create a conducive environment for the implementation of interventions for adolescents and young people, and specifically for AGYW as shown above. However, implementation of some policies may be lagging behind due to a lack of practical guidelines and implementation plans.

49 Eswatini National Youth Policy, 2009. 50 Zungu-Dirwayi, N. et.al., 2004. An Audit of HIV/AIDS Policies in Botswana, Eswatini, Lesotho, Mozambique, South Africa, and Zimbabwe.

13 NATIONAL GEOGRAPHIC AND PROGRAMMATIC B. SCOPING OF AGYW

4. Statistical Snapshot

Demography

The Kingdom of Eswatini is a landlocked country in Southern Africa with an estimated land area of 17,364 km2. It shares its border with Mozambique to the East, the Republic of South Africa to the North, West and South. Eswatini is classified as a lower-middle income country. According to the Population and Housing Census 2017, the population of Eswatini is 1,093,238 comprised of 531,111 males (48.6 per cent) and 562,127 females (51.4 per cent). The sex ratio is 94 males per 100 females. The population can be described as young as the population pyramid indicates a high percentage of those aged 0−14 years making up 35.6per cent of the total. The population in the 15−64 year-old age group is 59.9 per cent while those in the age-group of 65 years and above is 4.5 per cent.51

The total population of AGYW aged 15−24 years is 113,452 with adolescents aged 15−19 years totalling 59,213 and young women 20−24 years at 54,239. The total female population for the country is 562,127, meaning AGYW 15−24 years account for 20.2 per cent of the female population. This figure increases to 31.5 per cent including girls aged 10−14 years.52

HIV epidemiology

Data from the second Eswatini HIV Incidence Measurement Survey (SHIMS 2) (July 2017) indicates that prevalence of HIV among adults aged 15 years and older is 27 per cent (32.5% among females and 20.4% among males).53 It further states that since the first survey in 2011, new infections fell by nearly half, and viral load suppression among people living with HIV more than doubled. While the SHIMS 2 results reveal that achieving the 90-90-90 targets is a near reality in Eswatini, recent data from the 15th National HIV Semi-Annual Review (NaHSAR 15; data from July/December 2016) and a 2015 key populations mapping exercise highlight the need for innovative approaches to find, test, treat and support the hardest-to-reach populations in order to reach 90 per cent coverage.54 HIV incidence also still remains persistently high among adolescent girls and young women.

51 Central Statistical Office, 2017. The 2017 Population and Housing Census Preliminary Results. 52 Ibid. 53 Government of the Kingdom of Eswatini, 2017. Eswatini HIV Incidence Measurement Survey 2: A Population-Based HIV Impact Assess- ment SHIMS2 2016–2017. 54 Eswatini TB-HIV Funding Note (Final) 20 August 2017. 14 NATIONAL GEOGRAPHIC AND PROGRAMMATIC SCOPING OF AGYW B

Knowing one’s HIV status is the doorway to receiving treatment, care and support, yet most young people in Eswatini do not know their status. According to the Population-Based HIV Impact Assessment 2017, only 66.1 per cent of HIV- infected people aged 15−24 years know their HIV status, compared to 84.7 per cent in the adult population. Adolescent girls (AG) and young women (YW) in Eswatini account for a larger proportion (71 per cent) of new HIV infections among their age group compared to their male peers and HIV prevalence among females aged 20−24 years is more than five times higher than that of their male counterparts.55 The Multiple Indicator Cluster Survey (MICS) 2014 Report noted that three-quarters of AG aged 15−19 years are sexually active but only 40 per cent know their HIV status.56 Economic and social pressures fuel transactional and intergenerational sex, leaving AGYW even more at risk of HIV infection. Below is a summary of indicators on AGYW.

Table 2: HIV, Knowledge and Sexual Behaviour Indicators for AGYW aged 15−24 years

INDICATOR TOTAL NUMBER/RATE Living with HIV (15−24 years) 23,195* • Male 3,677* • Female 19,518* New infections (15−24 years) 2,724* • Male 475* • Female 2,249* HIV prevalence (15−24 years) 9.7%* HIV incidence per 1000 (15−24 years) 1.26* Per cent reduction in new HIV infections since 2010: (UNAIDS 2017) • 15−19 years -40% • 20−24 years -29% • AGYW -35% Projected % increase in population size between 2016 and 2030 (UNDP) • 15−19 years 16% • 20−24 years 8% 24% Percentage of women age 20−24 years who had at least one live birth before age 18 16.7% (MICS 2014) Adolescent birth rate per 1000 girls 15−19 years 87 Comprehensive knowledge/Knowledge about HIV prevention among young people (15−24) 49.1% (MICS 2014) Sexual debut before age 15 3% (MICS 2014) Sex with partner 10 years or older 15% (MICS 2014)

*Estimates as of April 2018

55 Population-Based HIV Impact Assessment 2017 56 CSO and UNICEF. 2016. Multiple Indicator Cluster Study 2014

15 5. Programme Results

The government of Eswatini is implementing varied packages of services to address the HIV epidemic in the country detailed in the section below on intervention mapping. This section highlights programme results looking at indicators on social structural factors, intervention coverage for AGYW, and intervention coverage among male partners summarised in table 3.

Table 3: Programme Results

INDICATOR RATE Social structural factors Secondary school attendance Secondary school completion Use of mass media Married before age 15 1.3% (MICS 2014) Married before age 18 8.8% (MICS 2014) Intimate partner violence Intervention coverage Condom use (GoK of Eswatini 2017/18 SADC Report) Men 15−49 years 26,022,145 (25,399,895 male condoms) (622,250 Female condoms) HIV testing Ministry of Health (2017) AGYW (15−24 years) 160,578 Men 15−49 years 382,781 Number of AGYW on ART 11,491 (Ministry of Health 2017) Intervention coverage among Number of men 15−49 circumcised 25% (MICS 2014), male partners Number of men 15 and above on ART 49,587 (2016); 54,922 (2017); 71,307* (2018) AGYW 15−20 years virally suppressed 8,744

*Estimates as of April 2018 6. Intervention Mapping

In addressing the education, health and social welfare issues of adolescent girls and young women in Eswatini, the Government of the Kingdom works through the Ministry of Health, the Ministry of Education and Training, the Ministry of Sports, Culture and Youth and other relevant government departments and institutions. Development and implementing partners and stakeholders provide support to government to fulfil its goals and objectives. One of the priorities is reaching adolescent girls and young women with SRH, and HIV and AIDS services. The discussion below highlights some of the programmes currently being implemented, and in some cases those planned for these population sub-groups: adolescent girls 10−14; adolescent girls 15−19; young women 20−24 years; male sexual partners of AGYW 15−24 years and male sexual partners of AGYW 25−54 years.

Young women’s access to standard package of SRH/HIV services (including condoms, HIV Test Services) ensured through specific actions, STI treatment and diagnoses)

Eswatini is implementing the National Policy on Sexual and Reproductive Health of 2013. The ASRH curriculum is being rolled out in tertiary institutions, for example at the Southern Africa Nazarene University (SANU) where students 16 NATIONAL GEOGRAPHIC AND PROGRAMMATIC SCOPING OF AGYW B

are sensitised on SRH/HIV issues and services. The country has launched a new condom strategy. Condom promotion and distribution is one of the key components in Eswatini’s combination prevention strategies to reduce the risk of HIV exposure including the transmission of STIs and unintended pregnancies. The Kingdom of Eswatini has also put in place a national condom committee, set up and constituted under the Ministry of Health’s leadership with support from other key stakeholders in the country. In 2017 a total of 26,022,145 condoms were distributed in the country. Female condoms constituted 2 per cent (622,250) of the distributed condoms and male condoms constituted 98 per cent (25,399,895).57 Condoms are promoted and distributed through health facilities, cultural events and through dispensers located in wash rooms. Condoms are not distributed in schools but information is disseminated through Life Skills Education. Notwithstanding, the Child Protection and Welfare Act, 2012 provides for the right of a child to access health care services from the age of 12 years.

PEPFAR is supporting the government in the provision of HIV Testing services (HTS). The DREAMS project, through its mobile clinics and outreach services (‘DREAMS on Wheels’ mobiles), targets AGYW 15−24 years with comprehensive SRH services, HTC, condoms and contraceptive method mix. Of the five Mobile Clinics, two focus on adolescent boys and young men (ABYM) ‘Esangweni Services’ but AGYW are also provided with services. The mobile clinics service communities on a daily basis. PEPFAR support is channelled to 24 Tinkhundla, and the Global Fund is funding another 19. The Young Heroes, under NERCHA, work at community level supporting young people living with HIV. They refer cases to health facilities using the Ministry of Health (MOH) referral note.

In 2017, there were 477,559 tests performed with a 5.5 per cent HIV positivity rate. Of those tested 38.6 per cent were adolescents and young people (see table 4).58

Table 4: Number of HIV Tests and Positivity for Adolescents and Young People 2017

NUMBER NUMBER NUMBER RECEIVED NUMBER NUMBER HIV REFERRED POSITIVITY AGE GROUP TESTED RESULTS TESTED POSITIVE FOR HIV CARE RATE (%) 10−14 years 23,861 23,853 12,545 337 282 1.4% 15−19 years 61,660 61,605 32,233 1,490 1,326 2.4% 20−24 years 98,918 98,809 50,709 4,533 4,065 4.6%

The NGO Pact, in partnership with Elizabeth Glaser Paediatric AIDS Foundation (EGPAF) and John Hopkins Center for Communication Programs (CCP), is implementing the Eswatini Ready, Resourceful and Risk Aware Project (Triple R) (locally named the Insika ya Kusasa project).59 The goal of the five-year project is to prevent new HIV infections and reduce vulnerability among orphans and vulnerable children (OVC), AG, and YW in Eswatini through the provision of education support, psychosocial support, HIV prevention services, mentorships, family planning services, and STI screening. Caregivers and parents receive economic strengthening support and parenting skills. The project helps HIV-negative OVC, AG, and YW stay HIV-free and support those who are HIV-positive to lead healthy lives. There is index testing in households of those OVC who test HIV positive. The project targets male and female OVC 0−17 years; adolescent girls 15−19 years; young women 20−29 years; and biological and non-biological female caregivers of OVC. Pact works at delivery level in Manzini, Lubombo, Hhohho and Shiselweni, with eleven implementing partners, four of whom focus on GBV.

57 Government of the Kingdom of Eswatini. 2018. Eswatini HIV and AIDS Annual Report to SADC 2017/18 58 Ministry of Health, HIV 2017 Annual Programme Report. 59 Eswatini Ready, Resourceful, Risk Aware (Triple R) (locally named Insika ya Kusasa), April 2018. 17 Family Life Association of Eswatini (FLAS) is implementing a comprehensive sexuality education programme for adolescents and young people aged 10−24 years inclusive of those living with HIV, LGBTIs, those with disabilities, sex workers and other vulnerable youth. Services are provided through three static facilities, five mobile clinics and one youth-friendly clinic attached to a youth recreational centre. The services encompass condom promotion and distribution, information on SRH/HIV and AIDS, addressing stigma and discrimination. Information is disseminated through multiple channels that include campaigns and social media. To increase participation of the youth, five committees running FLAS Youth Centres have youth representation. Funding for the programme is from the International Planned Parenthood Federation (IPPF), the Global Fund through CANGO, and Voluntary Service Overseas.

The Government of the Kingdom of Eswatini has introduced HIV self-testing (HIVST),60 complementary to the existing approaches for HIV testing. Approaches to HIVST include community and facility based HIVST in both public and private sectors. HIVST is integrated at both public and private health facilities. All clients seeking health services can be offered an opportunity to self-test for HIV while waiting for other services or be provided with a self-test kit to take home for use on themselves or distribution to a sexual partner.

At community level, HIVST is offered to community members and targeted populations such as key populations, youth and adolescents through existing community-based structures such as VCT centres, community-based HTS counsellors, Drop in Centres (DICEs), and during outreach services. With funding support from UNICEF, Lusweti Institute for Health and Development Communication is implementing an HIV Self Testing programme in 3 Tinkhundla in Lubombo region focusing on in- and out-of-school adolescents and young people. Trained self-test ambassadors facilitate Viewership Clubs that disseminate information on HIV and AIDS and emphasize the need to know one’s HIV status. The programme has carried out awareness activities, interventions to improve perceptions of HIV risk, and awaits receipt of self-test kits from the National HIV Programme.

Community mobilization for young women and male partners (including Stepping Stones, SASA or equivalent)

CANGO applied for funding from the Global Fund to support the provision of pre-paid vouchers and education subsidies to increase uptake of services for specifically vulnerable AGYW in high density, low-income areas, facilitate school re-entry for those who are able and interested to continue with formal education, as well as ensuring adequate knowledge and access to HIV, TB and SRH information. The intervention will utilize the Stepping Stones approach to capacitate out-of-school AGYW through peer educator and facilitator networks with comprehensive HIV knowledge and skills. Community AGYW and other role models will be supported to play an active role as champions for demand generation among AGYW. The out-of-school curriculum will also place emphasis on issues of healthy relationships (partners, family, peers), SGBV, sexual health, contraception, gender norms, and negotiating condom use. It will strengthen AGYW agency by including a focus on AGYW empowerment.

PrEP access

There are a number of ongoing and planned Pre-exposure Prophylaxis (PrEP) Open Label, demonstration and implementation projects in Eswatini since 2017. Even though the programmes target at-risk individuals, the DREAMS, ECHO, Linkages, and the Expanding Options for HIV prevention programmes target AGYW. AGYW at high risk can access PrEP even if they are not sex workers, mostly for very/extremely high incidence. The projects are funded by USAID, the Bill & Melinda Gates Foundation, PEPFAR, Nike Foundation, Heidelberg Institute of Public Health, and

60 Government of the Kingdom of Eswatini. HIV Self-Testing - Standard Operations Procedure for the Delivery Of HIV Self-Testing Services In Eswatini. 18 NATIONAL GEOGRAPHIC AND PROGRAMMATIC SCOPING OF AGYW B

Mylan.61 Starting from July 2017, PEPFAR, through Family Health International (FHI) 360, supported the implementation of a PrEP demonstration project (pilot) in the Mbabane-Manzini corridor targeting 600 young women and female sex workers (COP 16) while COP 17 targeted 1,300 female sex workers, vulnerable young women, high-risk pregnant women and men having sex with men (MSM).62 Currently under the demonstration project, PrEP is available in 22 health facilities and is to be scaled up to 200 facilities by 2019.

Social protection (including cash transfers both conditional and unconditional)

MICS data shows an increase in the percentage of children who are classified as orphans and vulnerable children (OVC), from 45 per cent in 2010 to 71 per cent in 2014.63 Eswatini runs social protection progammes which cater for adolescents and young people, among other groups. In 2016, an OVC cash transfer pilot programme was initiated, fully funded by the World Bank. The first payment covered 5,518 OVC from 1,312 households in the period 11−14 May 2016, while the second payment covered 7,063 OVC in the period October to November of the same year, most of which were in the 6−13 years age group.64 Additionally, a total of 58,800 beneficiaries from 9,800 households received cash from Baphalali Eswatini Red Cross Society (BSRCS) and 27,955 beneficiaries received assistance from the World Food Programme (WFP) through a drought response social cash transfer programme. In total, 86,755 beneficiaries (15,391 households) were reached through cash transfer with total direct cash amounting to Emalangeni 25.27 million (USD 1.7 million65) from BSRCS and WFP.66

Keep girls in school (including cash, incentives, vouchers, girl-friendly schools, policy change, or other support for vulnerable young women)

Keeping girls in school delays sexual debut, early pregnancy and marriage. The 2016 Annual Education Census noted varied reasons for girls and young women dropping out of school due to pregnancy accounting for the highest numbers. Of the 1,528 girls who dropped out of secondary school in 2016, 41 per cent was due to pregnancy, 17.9 per cent transfer, 15.3 per cent had absconded, 14.6 per cent cited family reasons, 5.2 per cent due to schools, and the remaining 6 per cent due other reasons (sickness, expelled/disciplinary, or death).67 At senior secondary, a similar picture is shown with 47.5 per cent of the drop-out cases due to pregnancy.

Interventions being implemented in Eswatini aimed at keeping girls in school include the cash transfer programme and the provision of dignity packs funded by Global Fund through CANGO and the Girls Empowerment Programme with Bantwana Initiative. With funding from USAID, World Education Inc.’s Bantwana Initiative (WEI/Bantwana) is implementing a two-year DREAMS innovations programme aimed at reaching 1,800 at-risk girls in Sithobela and Siphofaneni.68 The goal of the programme is to retain girls in secondary school, and reach adolescent wives and young mothers who were forced to drop out of school by offering alternative non-formal education platforms.

61 https://www.prepwatch.org/Eswatini-close-up/ 62 Detailed PEPFAR Activities for COP 17. 63 Central Statistical Office and UNICEF, 2016. Eswatini Multiple Indicator Cluster Survey 2014. Final Report. Mbabane, Eswatini, Central Statistical Office and UNICEF. 64 UNICEF, 2017. Social Protection Budget Eswatini 2017/2018. 65 Exchange rate 1USD=14.5 Emalangeni 66 UNICEF, 2017. Social Protection Budget Eswatini 2017/2018. 67 Ministry of Education and Training. 2016. Annual Education Census (AEC) Report 2016 Education Statistics 68 World Education’s Bantwana Initiative in Eswatini

19 Comprehensive GBV response

Eswatini has high rates of gender-based violence (GBV) (with 38 per cent of 18−24 year-olds having experienced sexual violence during their lifetime and significant gaps in GBV service referrals (two out of every three cases going unreported).69 A 2016 National Study on Key Drivers of Violence against Children (VAC), by the Department of Social Welfare in Eswatini, indicated that the key drivers of violence are poverty and inequality; gender norms and gender inequality; the HIV and AIDS epidemic; family and community secrets; and aspects of formal and informal child protection systems that limit disclosure, reporting and follow-up of violence cases.70 The VAC study was funded by UNICEF. Under the Deputy Prime Minister’s Office, Department of Social Welfare, the country has a paper-based National Surveillance System on violence, a national mechanism for collecting, collating, analysing and disseminating data/statistics on reported cases on all forms of violence from key national stakeholders working in this area.71 However, a gap has been noted in reporting of cases. A national strategy for the prevention and response to violence was developed and costed in 2017 which will facilitate the implementation of intervention to respond to violence.

The Department of Social Welfare is guided by the Children’s Protection and Welfare Act 2012 and the newly enacted Sexual Offences and Domestic Violence Act 2018 to assist with placement of children in need of protection, care and safety. The Department provides counselling, intermediary support in preparation for judicial processes and refers cases as per assessment. Presently, the country has three functional one-stop centres; one in Mbabane, attached to the High Court and launched in 2013; one in the Manzini Corridor and the third in Lubombo Region. Two of the three centres are attached to hospitals for comprehensive and 24-hour service provision to survivors of SGBV.

Under the school-based HIV prevention programme, the Swaziland Action Group Against Abuse (SWAGAA) runs school-based Girls Empowerment and Boys for Change Clubs to challenge and address harmful gender norms in Eswatini.72 Club members participate in guided discussions, songs and games in a manner that fosters a culture of equality and equity. Through these activities, SWAGAA club mentors teach about GBV, children’s rights, reproductive health and HIV/AIDS and sexual abuse. Mentors also work to cultivate leadership skills and confidence. Information, education and communication (IEC) materials supported by partners are disseminated through health facilities and in some schools. Further, HIV prevention messages and information about gender-based violence are disseminated during traditional events that bring young people before the King (Umhlanga and Incwala).

At the regional level, UNESCO adapted an international tool, ‘Connect with Respect’, which is to be adopted by countries in the East and Southern Africa region to address gender-based violence. Eswatini carried out the assessment upon which the results will be used to guide adoption of the tool in 2019.

Implementing partners supporting the Ministry of Health, Education, Justice, the Department of Gender and the police in the implementation of interventions to address sexual and gender-based violence include SWAGAA, Save the children, World Vision, Nhlangano AIDS Training Information and Counselling Centre (NATICC), and Cabrini Ministries, a faith-based community care organization. Funding support is mainly from Government, UNICEF, and the European Union.

69 Eswatini TB-HIV Funding Request (Final) 70 The Deputy Prime Ministers Office (DPMO) - Department of Gender and Family Issues, the University of Edinburgh (UoE), the University of Eswatini (UNISWA) and the United Nations Children’s Fund (UNICEF). A National Study on the Drivers of Violence Affecting Children in Eswatini, Mbabane: UNICEF Eswatini, 2016. 71 The National Surveillance System on Violence January – June 2017 Bulletin. 72 http://www.swagaa.org.sz/ 20 NATIONAL GEOGRAPHIC AND PROGRAMMATIC SCOPING OF AGYW B

Medical Male Circumcision (VMMC) for sexual partners of AGYW

Voluntary medical male circumcision (VMMC) for HIV prevention has been a priority for Eswatini since 2009. Initially focusing on men aged 15–49, the Ministry of Health reduced the minimum age for VMMC from 15 to 10 years in 2012, given the existing demand among 10- to 15-year-olds. VMMC programming runs under the Eswatini National AIDS Programme (SNAP) with funding support from PEPFAR, Johns Hopkins and Population Services International (PSI). PEPFAR supports the provision of comprehensive VMMC services to males aged between 10 and 49 years, with a particular focus on increasing demand among the 15- to 29-year-old group in all the four regions of the country.73 However, those aged 10 to 14 years and >29 are not denied services. This support is provided through static and outreach services with the Centre for HIV and AIDS Prevention Studies (CHAPS) as well as through mobile services coordinated by the Luke Commission.

Altogether 17,884 males were circumcised in 2017 with the 10−14 years age group having the highest proportion of males circumcised at 54.1 per cent (9,670/17 884) and the lowest being the 40−49 years age group with 0.8 per cent (143/17884) males circumcised. Looking at the cumulative number of males circumcised in 2017 according to the age disaggregation, it shows that 97 per cent were among the age group under and equal to 29 years which is in line with the recognized scale up of VMMC services in the country.74

Multimedia and new media (including Shuga, Soul City)

The Ministry of Sports, Culture and Youth coordinates a mobile app programme called ‘Tune Me’ through the Eswatini National Youth Council and FLAS. The media platform provides motivational content that inspires users to learn accurate and age appropriate information about SRH, HIV and AIDS, their own sexuality, personal risk, and protection methods. The platform currently hosts over 40,000 users.

UNICEF introduced and funded the U-Report, an SMS-based platform that promotes fast and participatory communication between providers and end-users. SMS polls and alerts are sent out to U-reporters and real-time response information is collected. Results and ideas are shared back with the community. Issues polled include − among others − health, education, water, sanitation and hygiene, youth unemployment, HIV and AIDS, disease outbreaks, and social welfare sectors. Working with five health facilities as a pilot, the U-Report is being used as a feedback mechanism on client satisfaction on service provision. The platform is managed by SWAGAA, Baylor College of Medicine and Super Buddies Clubs. Fifty-four per cent of U-Reporters are adolescents and young people aged 15−24 years.

Lusweti Institute for Health Development Communication is a non-governmental organization indigenous to Eswatini, dedicated to the creation and provision of innovative social behaviour change communication programmes. The Institute is focused on bringing social change to society ensuring that the majority of people in the country practice positive behaviour with respect to HIV/AIDS, health and development. Information is disseminated through social media platforms, print and electronic media, a toll free line, and IEC materials.

The Ministry of Health has two radio programme slots per week for all the programmes under the ministry. Indications from key informants are that the there are limited radio programmes for young people and there is no scheduled/ systematic programming on TV either. Respondents to the scoping exercise expressed the need to bring back the

73 Detailed PEPFAR Activities for COP 17. 74 Government of the Kingdom of Eswatini, 2018. Eswatini HIV and AIDS Annual Report to SADC 2017/18.

21 vibrant ‘Wise Up’ programme that was very popular with adolescents and young people. However, the programme was discontinued due to lack of funding. Notwithstanding, more interpersonal communication has been utilized, including multimedia and social media.

In-school activities for AGYW and boys aged 10−14 and 15−19 years

The Eswatini Government provides school-based prevention through the Care and Support for Teaching and Learning (CSTL) activity known as the Inqaba at primary level and the Life Skills Education (LSE) at secondary level. The Inqaba is implemented in primary schools through seven pillars: social protection; psychosocial support; food security; health; water, sanitation and hygiene; HIV, gender and life skills; and quality teaching and learning.75 The LSE has been rolled out in schools since 2013. Building on this, a new secondary school LSE curriculum was developed and scaled up in 2016. During the same period, a new primary school curriculum (mainstreaming LSE) was developed and is to be rolled out in 2019. The Global Fund, UNICEF, UNFPA and UNESCO, in partnership with the Ministry of Education and Training, have already invested in in-service teacher training. The country aims to ensure that by 2020 at least 75 per cent of young people (10–24 years) are reached with LSE in schools across the country.

The government, with support from UNESCO, is developing the National Life Skills Education Framework to govern messages disseminated in and out of school and by health services.

Treatment (ART) for sexual partners of AGYW treatment

Over the last decade, Eswatini has made great efforts to turn around its epidemic with improved access to HIV testing services and the provision of free antiretroviral treatment to those who need it. In 2014, the country adopted World Health Organization guidelines that anyone diagnosed with HIV should be started on ART regardless of their T lymphocyte (CD4) count. The Ministry of Health estimates indicate that 71,307 men age 15 years and above are on ART. Viral load suppression (VLS) among HIV-positive adults aged 15 years and older in Eswatini is 73.1 per cent (76 per cent among females and 67.6 per cent among males).76 PEPFAR is the largest contributor of funding for Eswatini’s HIV treatment programme, followed by the Eswatini government and the Global Fund (see the investment profile in table 5).

Programmes focusing on adolescent boys and young men

There are various organizations in Eswatini focusing on adolescent boys and young men. One of these implementing partners is Kwakha Indvodza. Programming in HIV and AIDS with adolescent boys and young men aims to address the bi-directional transmission as younger women engage in sexual relationships with older men who in turn can infect their wives. Similarly, older men engage in sexual relationships with young girls, who can infect young men in situations of multiple concurrent relationships. The programmes focus on financial independence and literacy; economic empowerment; social responsibilities; HIV prevention; advocacy against sexual and gender-based violence; and re-defining masculinity in a patriarchal society. The organization is funded by USAID/PEPFAR, UNAIDS, and UNICEF.

75 Ministry of Education and Training, 2011. Inqaba Implementation Manual. 76 SHIMS 2, Summary Report, Second ADS Review.

22 NATIONAL GEOGRAPHIC AND PROGRAMMATIC SCOPING OF AGYW B

7. Coordination

Eswatini’s HIV response management principles encompass the “Three Ones” approach; that is, one coordinating structure, one strategic HIV response framework and one M&E system. NERCHA is responsible for coordinating all structures including sectors, stakeholders, development partners, regions and HIV service implementers. HIV coordination is defined through sectors and the decentralized regional multi-sectoral structures. NERCHA has decentralized the coordination into the four regions of the country. The regional coordination is mainstreamed to the existing structures in the country such as Regional Multi-Sectoral HIV and AIDS Coordinating Committees (mainstreamed into the Ministry of Tinkhundla and Administration), formed by selected members of the regional development teams. Other levels of the decentralization include the Tinkhundla and community. All decentralized regional, constituency and community structures are in line with the National Decentralization Policy of 2005.

The Ministry of Health leads the health sector response to HIV and AIDS, through the SNAP which was established in 1987. The programme is responsible for providing technical leadership and coordination of the health sector response, implementing HIV prevention, treatment, care and support and supportive cross-cutting and health system interventions in the health sector as outlined in the Health Service Regional Plan 2014−18.77

In the implementation of each thematic areas’ activities, there are Technical Working Groups (TWGs) who provide technical guidance in each area of the HIV/AIDS response. The TWGs in place focus on different themes such as HIV Prevention, SRH, Adolescents and Youth Sexual Reproductive Health (AYSRH), GBV, OVC, and clinical care. AGYW issues fall under the AYSRH TWG which has approximately 43 partners. The TWG is led by the Ministry of Health, the Ministry of Education and the Ministry of Sport, Culture and Youth with rotational chairmanship. The AYSRH TWG meets on a quarterly basis and partners report on progress in programme implementation. The platform is also used for knowledge and information sharing on programmes and research relevant to adolescents and young people. These TWGs are chaired by each thematic area lead at SNAP and comprised of members of different stakeholders within the health sector including the MOH (programmes, Departments and Units), implementing partners, civil society organizations and academia (private sector included).

A Consolidated Annual Action Plan which tables programme activities to be focused on is developed with all partners. Development partners pledge support to activities in the Action Plan, and fund the activities directly. The Action Plan has four areas of focus, namely: Policy and Legal; Advocacy; Capacity Development; and Research, Monitoring and Evaluation. Implementing partners are assigned to regions. For example, currently ICAP (Colombia University) is in Manzini; EGPAF is implementing programmes in two regions (Hhohho and Shiselweni), while University Research Co. (URC) is working in Lubombo Region.

The MOH has developed an AYSRH Dashboard which records information on adolescents and young people in health and education. The data however is not up to date, except for the health section by MOH.

77 Ministry of Health. 2017, Annual Report. 23 8. Key Global Investments

Eswatini’s total Global Fund (GF) allocation has decreased by about one third, from USD 80.4 million in the 2014−2016 funding cycle to USD 51.3 million in the 2018−2021 funding cycle. The country received approximately USD 898.40 million in overseas development assistance between 2011/12 and 2015/16, averaging USD 149.74 million annually.78 The health sector has been the largest beneficiary of external assistance; the HIV/AIDS and TB epidemics have received a significant response from global development partners and donors.

Donors support critical areas in HIV/TB care, treatment, and prevention, including direct service delivery, technical assistance, some commodities, and human resources (HR). Nonetheless, viral load scale-up and the complete roll-out of the Client Management Information System (CMIS) require additional donor support.

PEPFAR is the largest contributor to the HIV response, followed by GKoE, and then the Global Fund. Since 2009, GKoE has remained committed to funding ARVs, HIV test kits, and lab reagents. PEPFAR and GF, however, continue to provide stop-gap support and provision of specific commodities that are difficult for GKoE to procure at the smaller volumes required by the country given that PEPFAR and GF are major procurers of reagents and testing equipment at the global level. At GKoE’s request of 2015, PEPFAR agreed to supply all the public sector with free and socially marketed condoms for health programmes in-country. PEPFAR is also the main supporter of HIV prevention programming including VMMC, oral PrEP, and comprehensive interventions and services for adolescent girls and young women, OVC and key populations. PEPFAR is funding the five-year ‘Triple R’ Project to the tune of USD 40 million to be implemented through Pact. Pact intends to award initial two-year grants between USD 912,000 (E 10,488,000) and USD 1,172,571 (E 13,484,571) in total funding for the OVC/HIV prevention technical area and between USD 198,000 (E 2,277,000) and USD 264,000 (E 3,036,000) for the GBV/Post-Abuse Care technical area.79

In 2018, a total of USD 124,149,541 was secured for COP 2018 Vision for Eswatini programming in the areas of clinical care, treatment and support; community-based care and support; PMTCT; HTC; VMMC; priority population prevention; key population prevention; OVC; lab and blood safety; strategic information, surveys and surveillance; and health system strengthening (HSS).80 The investment for these programmes in 2018 came from the Government of Eswatini and development partners as indicated in Table 5. PEPFAR contributed 49% of the total expenditure, 25% from the government, 21% other partners and 5% from the Global Fund.

78 PEPFAR Eswatini Country Operational Plan (COP) 2018 - Strategic Direction Summary, March 15 2018. 79 Ibid. 80 COP 2018 Vision Eswatini, Internal Use Only COP 2018 Regional Planning Meeting, February 19, 2018.

24 NATIONAL GEOGRAPHIC AND PROGRAMMATIC SCOPING OF AGYW B

Table 5: 2018 Investment Profile by Programme

PROGRAMME AREA TOTAL % % GLOBAL % OTHER EXPENDITURE PEPFAR FUND GOVERNMENT Clinical care, treatment and support $51,623,860 31% 4% 35% 31% Community-based care, treatment and support $4,407,445 93% 0% 1% 6% PMTCT $4,282,658 77% 2% 0% 21% HTC $6,897,818 96% 0% 2% 2% VMMC $5,141,030 76% 24% 0% 0% Priority population prevention (prisons, migrant $8,622,975 87% 3% 0% 10% workers, miners) Key population prevention (MSM, sex workers) $1,153,712 94% 6% 0% 0% Orphans and vulnerable children $18,278,611 33% 3% 56% 9% Lab and blood safety $9,701,417 45% 18% 26% 11% Strategic information, surveys and surveillance $4,996,658 91% 9% 0% 0% Health system strengthening $9,043,358 37% 5% 2% 56% Total $124,149,541 49% 5% 25% 21%

25 GEOGRAPHIC AND PROGRAMMATIC SCOPING OF AGYW IN 3 TINKHUNDLA GEOGRAPHIC AND PROGRAMMATIC SCOPING C. OF AGYW IN 3 TINKHUNDLA

9. Statistical Snapshot of the Three Tinkhundla

Mahlangatja is a rural Inkhundla in the Manzini region, situated about 85kms from Manzini town and about 30kms from Mankayane town. The total population for the Manzini region is 355,945 accounting for 32.6 per cent of the 1,093,238 total population of Eswatini. Of this population, 17,877 reside in Mahlangatja (male, 8,561; female, 9,316).81

Mhlume is a semi-urban area with informal settlements located in Lubombo Region. The total population for Lubombo is 212,531 (19.4 per cent of the country’s population). Of this population, 16,510 reside in Mhlume (male, 9,713; female, 6,797).82

The total population for Shiselweni region is 204,111 (18.7 per cent of the country’s total population). Of this population, 8,357 reside in Somntongo (male, 3,869; female, 4,488).83 Somntongo is a rural Inkhundla, about 45km away from Big Bend Town.

The 2017 Population and Housing Census Preliminary Report presents disaggregated data by sex and age at national and regional levels.This Report uses the regional rates to estimate the number of AGYW per Inkhundla as presented in table 6. The estimated number presented includes both in and out-of-school of adolescent girls and young women aged between 10 and 24 years.

Table 6: Number of AGYW age 10 to 24 by Inkhundla

AGE GROUP % OF ESTIMATED AGYW % OF ESTIMATED % OF ESTIMATED AGYW IN MAHLANGATJA AGYW IN AGYW AGYW IN AGYW IN MANZINI (TOTAL F = 9,316) LUBOMBO INMHLUME SHESELWENI SOMNTONGO (TOTAL F = 6,797) (TOTAL F=4,488) 10−24 years 30.5 2,841 32.2 2,189 33.2 1,490 15−24 years 20.2 1,882 20.1 1,366 19.8 889

81 Central Statistical Office, 2017. The 2017 Population and Housing Census Preliminary Results. 82 Central Statistical Office, 2017. The 2017 Population and Housing Census Preliminary Results. 83 Central Statistical Office, 2017. The 2017 Population and Housing Census Preliminary Results. 26 GEOGRAPHIC AND PROGRAMMATIC SCOPING OF AGYW IN 3 TINKHUNDLA C

10. Socioeconomic Environment

Objective 1: Determine HIV, health, education, social services, GBV response, justice/police, community-based organizations based in the geographical areas and their scope of work.

10.1 Living Arrangements for AGYW

The scoping exercise contributed to the understanding of the living arrangements of AGYW in the three selected Tinkhundla. Generally, the living arrangements vary across the three Tinkhundla, with AGYW living with their parents, mothers, grandparents, other relatives, or are in child-headed households. The 2017 Population and Household Census noted that a majority of the population (97.91 per cent) lives in regular households.84

Most AGYW in Mahlangatja Inkhundla live with their parents and/or grandparents while some live with other relatives (aunts and uncles), and just a few live in child-headed households. Some of the AGYW have babies, indicating that they engage in unprotected sex. The AGYW living with grandparents rely on the government-supported elderly persons grant of E 200 (equivalent to USD 14) per month, which was described as inadequate to cater for the household.

Some of the parents reside in Matsapha and its environs, where they work at the busy industrial site; they use mobile money platforms to send money home to support their families. Only a minority of the parents are employed in the nearby farms where they work as labourers, while some are domestic workers. Some parents and guardians are self- employed making mats, gardening (growing vegetables), while others are said to be growing dagga.

Mhlume Inkhundla is a mix of rural, peri-urban and informal settlements. There are informal settlements at Vuvulane and Mgidzangcunu with houses built from tiny poles and mud. The houses have no electricity and the residences rely on one communal tap for their water requirements. People living in the settlements are employed seasonally as unskilled labourers at the Royal Swaziland Sugar Company (RSSC).

In Mhlume Inkhundla, out-of-school AGYW reside mainly in the Mgidzangcunu squatter camp near the RSSC. Indications are that some of the AGYW have dropped out of school due to lack of school fees for their secondary school education. Secondary school education is not free in Eswatini. In-school AGYW from Mhlume, Simunye and Ngomane High Schools live with their fathers who are employed as skilled labourers at the RSSC. Some AGYW live with their siblings, and rent flats by themselves while some stay in school hostels.

Most AGYW in Somntongo Inkhundla live with their mothers and/or grandmothers, as men from the area usually migrate to work in South Africa (Phongola). Some of the mothers are employed in the textile factories in Matsanjeni about 20km outside the chiefdom, while others live by making hand crafts through support from an organization called Bomake Gone Rural which trains women to make crafts and organize international markets for their produce. The women working in textile factories are forced to relocate to live near the firms, leaving their children residing by themselves. To avoid transport costs, these women send financial support to their child-headed families. Grandmothers supporting AGYW are not able to help the young girls with their basic needs as they depend on a E 200 elderly persons grant per month. A small percentage of AGYW live alone in child-headed homes and are usually helped by neighbours with basic necessities such as food and sanitary wear.

84 Ibid 27 GEOGRAPHIC AND PROGRAMMATIC SCOPING OF AGYW IN 3 TINKHUNDLA

10.2 HIV and AIDS

Adolescent girls and young women in Mahlangatja, Mhlume and Somntongo access HIV/AIDS services (testing, counselling, treatment, care and support) and contraceptives from local clinics. AGYW can easily access male and female condoms from the clinics. In Mhlume, condoms are also distributed at a community library which is accessed by all members. Ngomane Clinic in Mhlume provides door-to-door HIV testing and those who are negative are encouraged to donate blood during those sessions. Additional information on organizations implementing HIV and AIDS interventions in the Tinkhundla are presented in Section 2.6.

The scoping exercise further sought to establish the factors that make AGYW vulnerable to HIV infection. The factors raised include early sexual debut, drug and substance abuse, sexual abuse, transactional and intergenerational sex, early marriage, inconsistent use of condoms, multiple concurrent partners, non-disclosure of HIV status, and cultural beliefs. These are discussed in detail below.

i. Early sexual debut The AGYW in the threeTinkhundla become sexually active at an early age and do not use condoms to protect themselves against HIV infection and unwanted pregnancy. Information gathered through focus group discussions and in-depth interviews show evidence of early pregnancy as adolescent girls as young as 15 years have been reported to be pregnant. Eswatini MICS 2014 noted that the percentage of young people aged 15−24 who had sexual intercourse before age 15 was 3 per cent for women and 2.8 per cent for men.85 Even though it is culturally and socially acceptable for young girls to have a child, there is a perception of risk for adolescents who engage in sexual relationships at an early age as expressed by the two key informants below.

The youth are very sexually active and they don’t use condoms − evidence of this being that the girls get pregnant as early as 15 years. Key informant, Mhlume Inkhundla

The young girls have no role models in the community because every girl is having a baby, so they copy that kind of behaviour and also have babies themselves. Key informant, Somntongo Inkhundla

ii. Sexual abuse Eswatini has high rates of gender-based violence (GBV) with 38 per cent of 18−24 year-olds having experienced sexual violence during their lifetime and there are significant gaps in GBV service referrals (two out of every three cases going unreported).86 A 2016 national study on key drivers of violence against children in Eswatini indicated that the key drivers of violence are poverty and inequality; gender norms and gender inequality; the HIV and AIDS epidemic; family and community secrets; and aspects of formal and informal child protection systems that limit disclosure, reporting and follow-up of violence cases.87

85 Central Statistical Office and UNICEF, 2016. Eswatini Multiple Indicator Cluster Survey 2014. Final Report. Mbabane, Eswatini, Central Statistical Office and UNICEF. 86 Eswatini TB-HIV Funding Request (Final). 87 The Deputy Prime Ministers Office (DPMO) - Department of Gender and Family Issues, the University of Edinburgh (UoE), the University of Swaziland (UNISWA) and the United Nations Children’s Fund (UNICEF). A National Study on the Drivers of Violence Affecting Children in Swaziland, Mbabane: UNICEF Swaziland, 2016.

28 GEOGRAPHIC AND PROGRAMMATIC SCOPING OF AGYW IN 3 TINKHUNDLA C

Cases of sexual abuse and violence were talked about by key informants and by participants in focus group discussions in the scoping exercise. Indications are that there are such cases but some are not reported as they are guarded as family secrets.

… it is known that some of the young girls are abused by their relatives and the families do not want such cases to be publicized, thus they refer to them as ‘tibitendlu’ meaning family matter. In siSwati, family matters are kept private and not discussed with outsiders. Key informant, Mahlangatja Inkhundla

Some girls are abused sexually in the family, for example by an uncle but are forced to keep quiet by their parents as it is believed that family issues should be kept in the family. FGD, out-of-school participant aged 20−24 years in Mhlume Inkhundla

Advocacy and sensitisation on the enacted Sexual Offences and Domestic Act 2018, can encourage communities to report cases of sexual abuse and violence. This is paramount so that the survivors of abuse can receive necessary counselling, treatment and support.

iii. Transactional and intergenerational sex Adolescent girls and young women in the three Tinkhundla engage in sexual intercourse with older men in exchange for money and other favours. Due to the patriarchal nature of the society, the adolescent girls and young women in such relationships are unable to negotiate for condom use and the older men are known to be against the use of condoms. In Somntongo, the situation is worsened by its proximity to the border where the girls sell their bodies to truck drivers who park at the border. Comments from a focus group discussion with in-school young women aged 20−24 years from Mahlangatja sum up the situation:

The girls have ‘blessers’ who have a lot of money to spend. Young girls spend too much time in the relationships and end up having sex even when that was not the plan in the beginning.

Adolescent girls and young women succumb to peer pressure and end up engaging in sexual relationships with older men in order to live a more ostentatious lifestyle than their peers.

iv. Early marriage Some AGYW engage in sexual relationships with older men. In some instances this is done for money and in others through marriage to a man who already has a number of wives or a widower. Some girls are forced into marrying these older men especially if the man is perceived as rich. One of the factors that push some AGYW to the older man is poverty. The older men are perceived as ‘blessers’ as highlighted above.

Even the parents encourage the girls to marry these men because they will be able to provide for them and also take care of the girl’s family. Key informant, Mahlangatja Inkhundla

29 GEOGRAPHIC AND PROGRAMMATIC SCOPING OF AGYW IN 3 TINKHUNDLA

v. Inconsistent use of condoms Community perception is that some AGYW who are sexually active do not use condoms yet their partners are not faithful to one partner. Girls rely on their male partners to provide the condoms for a sexual encounter and most times the men do not provide them because they have no interest in using protection. Female condoms are not easily available. The failure of AGYW to negotiate for safer sex reflects the patriarchal power imbalance between men and women, and is an indication of how the girls and young are not assertive in the condom use discussion.

Girls need to be assertive and carry condoms themselves and not rely on the males. Both males and females need to reduce alcohol and drug abuse because once they are intoxicated they tend not to use condoms which put them at risk of contracting HIV. FGD, in-school adolescent girls aged 15−19 years in Mahlangatja

Most of the older men do not want to use condoms, and they threaten the girls that they will not pay them if they insist on using a condom. Key informant, Mhlume Inkhundla

... it difficult to negotiate condom use with an older man, so whatever the man says carries the day. FGD, in-school young women aged 20−24 years in Mahlangatja Inkhundla

vi. Multiple concurrent sexual partners Adolescent girls and young women have multiple concurrent partners. Some of the partners are their age mates while others are older men who give them money and neither of these partners adhere to consistent condom use.

Most of the boys and young men do not want to use a condom. FGD, out-of-school young women aged 20−24 years in Mhlume Inkhundla

vii. Non-disclosure of HIV status Focus group discussions with adolescents and young people brought out issues of non-disclosure of HIV status to some adolescents and young people pre-natally infected with HIV. It is assumed that those living with HIV may engage in sex without using condoms and unknowingly infect their partners. Secondly, adolescent boys and young men noted that once they learn of their HIV positive status they purposely infect others because “they do not want to suffer or die alone (awfunikufawedvwa)”. Non disclosure of HIV status and/or intentional infection of others are serious issues that may need further research for confirmation.

viii. Cultural beliefs Cultural beliefs also play a role in the vulnerability of AGYW to HIV infection as it affects their health seeking behaviour. Due to cultural and religious beliefs, some do not test for HIV and do not seek treatment because they believe that the sickness is caused by witchcraft. They do not seek medical care but alternative forms of treatment. The limited amount of information on health-seeking behaviour by AGYW in Eswatini does not allow for triangulation of data.

ix. Drug and substance abuse Drug and substance abuse was noted in the three Tinkhundla as an avenue that put adolescents and young people at a risk of HIV infection. Dagga is easily accessible in Mahlangatja Inkhundla as it is grown in the area. Key informants in the Inkhundla noted that young people smoke dagga and drink alcohol especially the young girls and boys. Information

30 GEOGRAPHIC AND PROGRAMMATIC SCOPING OF AGYW IN 3 TINKHUNDLA C

gathered from Mhlume indicates that, when injecting themselves with drugs, several young people appear to be using the same needle. In Somntongo, adolescents and young people engage in alcohol abuse and smoking dagga, to the extent that during the marula season, they prefer going to drinking spots than going to school. In their intoxicated state, they engage in experimental and unsafe sex.

The MICS 2014 results for men aged 15−59 years who smoked a cigarette for the first time before age 15 is 2.8 per cent. Among women, the corresponding percentage is less than one per cent. Similarly, use of alcohol before the age of 15 is more common among men (6 per cent) than among women (2 per cent).88

10.3 SRH and HIV and AIDS Services

The formal health sector is based on the concepts of primary health care and decentralization. Its infrastructure is made up of seven government hospitals, two mission hospitals and one industry-supported hospital. There are also 8 public health units, 12 health centres, 76 clinics and 187 outreach sites. In addition, there are 73 mission health facilities (health centres, clinics and outreach sites), 62 private clinics and 22 industry-supported health centres and clinics.89

Mahlangatja Inkhundla

There are four health facilities in Mahlangatja Inkhundla. For the Ekuphakameni community in Mahlangatja, there is a community clinic providing HIV testing services, ART, condom distribution and primary health-care services. However, the local clinic is located very far from the community and accessing the health services proves impossible, especially to young people. As a result of the long distance and lack of transport, young people do not access these services.

Over and above the distance to the clinic and the need for transport, adolescent girls aged 15−19 years who participated in a discussion group at Zamani High School indicated that they do not use the facility due to a perceived lack of privacy. This challenge is attributed to the size of the clinic, a small facility that has different consultation rooms especially for HTS, which makes it obvious and easy to identify clients seeking HTS. Coupled with the lack of privacy, it was highlighted that the attitude of health staff towards AGYW is another hindrance to accessing SRH and HIV and AIDS services. AGYW, however, are aware of the services they can access including information.

… the clinic provides health education sessions and pamphlets containing HIV and AIDS related messages. FGD, in-school adolescent girls aged 15−19 years, Mahlangatja

One clinic visited in Mahlangatja provides SRH and HIV and AIDS services, promotes and distributes condoms, offers HIV testing services, ART and other health services (see annex 2). Staff from the local clinic highlighted that they collaborate with other implementing partners that include Population Services International (PSI) and Cabrini Ministries. Once a month, PSI provides HIV testing, HIV and AIDS information, distribution of condoms, and ART. Cabrini Ministries also offer ART to the general public without specifically focusing on youth. ICAP also provides community ART services to people living with HIV who would have graduated to COMM ART.

Outreach activities with mobile clinics take place once a month in Mahlangatja Inkhundla. Médecins Sans Frontières (MSF) also provides a mobile clinic which services all community members, not necessarily focusing on AGYW. The mobile clinic provides HTS, and ART refills. Additionally, the Luke Commission visits the area frequently, providing

88 Central Statistical Office and UNICEF, 2016. Swaziland Multiple Indicator Cluster Survey 2014, Final Report. Mbabane, Swaziland, Central Statistical Office and UNICEF. 89 Ministry of Health, National Health Policy. 31 GEOGRAPHIC AND PROGRAMMATIC SCOPING OF AGYW IN 3 TINKHUNDLA

medical assistance for different ailments and eye glasses to those who need them. Some of the mobile clinic staff pay special visits to homesteads to provide TB treatment to those who are unable to visit the hospital or clinic.

Muhlume Inkhundla

During the scoping exercise, Data Collectors visited Ngomane Clinic and Vuvulane Rural Clinic in Mhlume Inkhundla. The government-owned Vuvulane Rural Clinic is located near to the community, making it easy for people, including AGYW, to access services. The clinic provides basic medical services, namely treatment of minor ailments, at no cost, and severe cases are referred to the Good Shepherd Hospital in Siteki. Further, there are clinics under RSSC at Lusoti, Ngomane and Mhlume which provide services at no cost to employees of the company while outsiders are expected to pay for services.

The Vuvulane community receives additional services through mobile clinics that service the whole community and not necessarily only AGYW. Other outreach activities are conducted by NERCHA. The main service offered by the mobile clinics is HIV testing. Members of the community exhibiting an HIV positive result are then referred to Good Shepherd for CD4 count and initiation on antiretroviral drugs. The RSSC also has mobile clinics that visit Tshaneni and offer HIV services and blood pressure checks, while the Children’s Intervention in Swaziland (CHIPS) offers HIV testing and ART refills.

Somntongo Inkhundla

Health facilities are located far away from the Mgampondo and Ezindwendweni communities in Somntongo Inkhundla. The main health facility is at Matsanjeni and the transport fare for the journey is E 22 (UD 1.6) while Khwezi Clinic is a E 10 fare ride away. Ezindwendweni Clinic is still under construction. At the Lavumisa border, there is a Northstar Clinic that was initially built for commercial sex workers but now provides services to all community members. The issue of the judgemental attitude of health service providers discussed earlier was echoed in Somntongo. One key informant noted that adolescent girls and young women choose to swap clinics for fear of victimisation by the nurses, meaning that those who reside near Lavumisa access services from Matsanjeni and vice versa.

... the nurses must be warned about their abusive behaviour. The maternity ward should be installed with cameras so the nurses can be exposed about their abusive doings. FGD, in- school adolescent girls aged 15−19 years, Somntongo

A UNICEF Eswatini 2015 Annual Report noted that among the supply bottlenecks addressed was the issue of inadequately skilled health care workers to provide integrated maternal, newborn and child health /HIV/Nutrition/TB services, and their attitudes towards patients.90

One mobile clinic run by Doctors without Borders brings services to the community, and not only for AGYW. The nurses from Matsanjeni Clinic also conduct outreach activities, bringing health services closer to the people. The map below shows the number of health facilities and schools in Mahlangatja, Mhlume and Somntongo Tinkhundla.

90 UNICEF Annual Report 2015. 32 GEOGRAPHIC AND PROGRAMMATIC SCOPING OF AGYW IN 3 TINKHUNDLA C

Health facilities and schools map

10.4 Education

The Government of the Kingdom of Eswatini has provided primary, secondary and high schools in the three TInkhundla of Mahlangatja, Mhlume and Somntongo. The schools in Mahlangatja include Sigcineni Primary and High School, Zamani Primary and High School, and Ndzeleni Primary School. In Mhlume, there are schools in Lusoti, Ngomane and Vuvulane. Primary and high schools in Somntongo are Mgampondo Primary, Ndabazezwe High school, Ezindwendweni primary, high schools, Etjeni and Mgampondo Primary Schools. Information from the community does not point to any challenges in the availability of schools. The issue that dominated the discussion around education is of learners dropping out of school. The main causes of school dropout cited include:

FDG, adolescent girls aged 15−19 at Zamani High School

Poverty: Secondary school education is not free in Eswatini. Parents and guardians pay fees for a learner to go through secondary education. Due to poverty, which is exacerbated by unemployment, adolescents and young people drop out of school because families are unable to cater for all their children’s school needs including uniforms, fees, bus fares and stationery. In Mhlume for example, the Mgidzangcunu community is an informal settlement/squatter camp, with parents seasonally employed in the nearby farms. Somntongo on the other hand is a rural community which

33 GEOGRAPHIC AND PROGRAMMATIC SCOPING OF AGYW IN 3 TINKHUNDLA

relies on agriculture. In the absence of adequate rains, parents do not achieve a sufficient harvest from their farming activities to support their livelihoods. Given this, parents are not able to pay for high school education for their children, resulting in learners dropping out of school. The Bantwana Initiative and the Taiwan Fund for Children (TFFC) provide subsidized education support but this does not reach all needy AGYW.

Teenage pregnancy and early marriage: Teenage pregnancy is high in all three Tinkhundla. Eswatini MICS 2014 noted an adolescent birth rate of 87 per 1,000. The report further noted that the percentage of women aged 20−24 years who had at least one live birth before age 18 was 16.7 per cent.91 A high rate of early marriages is reported in Mahlangatja, especially in the area called Mgomfelweni (one of the chiefdoms) where the community still condones the practice.

The 2016 Annual Education Census noted various reasons for girls and young women dropping out of school with pregnancy accounting for the highest numbers. Of the 1,528 girls who dropped out of secondary school in 2016, 41 per cent was due to pregnancy, 17.9 per cent transfer, 15.3 per cent had absconded, 14.6 per cent cited family reasons, 5.2 per cent due to schools, and the remaining 6 per cent due other reasons (sickness, expelled/disciplinary, or death).92 At senior secondary, a similar picture is shown with 47.5 per cent of the dropout cases due to pregnancy.

Cultivating and selling dagga: Even though AGYW may not be partaking in the cultivation and selling of dagga, the activity was noted especially amongst adolescent boys and young men who drop out of school to join the illegal growing and selling of dagga. Cultivating, selling and smoking dagga is illegal in Eswatini, however youth believe it is more profitable and better use of their time than schooling. They emulate some school dropouts who joined the illegal trade and are driving expensive cars and are perceived as living better lives.

Corporal punishment from teachers and parents: In Eswatini, corporal punishment of children is a legalised form of child-rearing in the home, at school, and as a sentence by a court.93 The scoping exercise finds that many boys and girls identified corporal punishment and other forms of humiliating and degrading punishment in the school as a reason for dropping out. Teachers punish students for misbehaving and/or for different misdemeanours. As part of the punishment, the teachers may ask them to dig up to 30 holes for coming to class late and in turn they arrive home late. Due to tiredness, the students fail to study and do homework which further subjects them to more punishment until they resolve to drop out of school. On the other hand, parents punish them for coming back from school late as they do not believe the child when they report that they were delayed at school. At home, the students are also expected to conduct chores such as watering gardens which consumes time that could be used for doing homework; in addition the home chores leave them too exhausted to do school work. This is said to result in students failing a grade and repeating classes for multiple times, which then discourages them from continuing with school.

The findings of a study by Dlamini et al. 2017 revealed that the effects of corporal punishment include an improvement in academic performance, students dropping out of school and some students becoming stubborn.94 A study by Shongwe in 2013 stated that in Eswatini the punishment of students by teachers is not limited to strokes of the cane, but includes methods such as a slap with the open hand, kicks and fists.95 The two studies indicate that corporal punishment is being practiced in schools in Eswatini, bringing to the fore the need to address the school environment.

Repeating a class: Another factor causing AGYW to drop out of school is repeating a class. Information from FGDs and from key informants indicates that some AGYW can repeat a class more than once, and as they are overtaken

91 Central Statistical Office and UNICEF, 2016. Eswatini Multiple Indicator Cluster Survey 2014. Final Report. Mbabane, Eswatini, Central Statistical Office and UNICEF. 92 Ministry of Education and Training, 2016. Annual Education Census (AEC) Report 2016 Education Statistics. 93 Country Report for Eswatini. https://endcorporalpunishment.org/reports-on-every-state-and-territory/eswatini/ 94 Dlamini L. K. et. al., 2017. The use of corporal punishment and its effects on students’ academic performance in Eswatini. IOSR Journal of Humanities and Social Science (IOSR-JHSS) Volume 22, Issue 12: 53−61 95 The study by Shongwe 2013 is cited in Dlamini et. al., 2017.

34 GEOGRAPHIC AND PROGRAMMATIC SCOPING OF AGYW IN 3 TINKHUNDLA C

by students who were once behind them, they feel discouraged. Secondly, when younger students who were behind join a repeater, the repeaters perceive themselves as too old to be in the same class with learners younger than them. These negative perceptions lead to dropping out of school.

Repeating classes lead to some of them dropping out ... they don’t want to be in same class with students much younger than them. They are demotivated ... FGD, out-of-school young men aged 20−24 years in Somntongo Inkhundla

Some get tired of failing and repeating classes. Key informant, Mhlume Inkhundla

The Annual Education Census 2016 shows that repetition is high. The repetition rate at lower secondary was 12.1 per cent for girls and 13.7 per cent for boys while it is 11.5 per cent for girls at senior secondary and 12.6 per cent for boys.96

Re-entry: The Ministry of Education and Training developed the National Education and Training Sector Policy 201897 which states the need to establish a non-formal education system that ensures provision of flexible learning pathways, entry points and re-entry at all education levels. Learners include out-of-school children, youth and adults, who have the opportunity to complete basic literacy and primary education through non-formal channels and proceed with secondary education and skills training via a number of institutions providing non-formal education, adult education and Lifelong Learning (LLL).

The development and implementation of this policy will make re-entry smoother than it currently is. Findings of the scoping exercise show that implementation of the re-entry programme depends on different circumstances such as the reason for dropping out, the school assessment of possibility of re-entry, and the learner to be re-integrated. The enrolling authorities seem to use their discretion in offering placement. The parents who participated in focus group discussions indicated that young girls are not allowed back to school because they are mothers and school authorities fear that returnees will be a bad influence on the other students.

However, some students and key informants indicated that re-entry was not a problem as students were allowed to continue attending classes even while pregnant until they finished writing their examinations, and former students were allowed to re-join the formal school system. Teachers are said to give special treatment to returning students who had left due to pregnancy to make them feel more comfortable and not discriminated. Nevertheless, the students shy away from re-entry, especially in attending the same school, due to self-discrimination or perceived stigma by the student, with some opting to enrol in another school.

Re-admission depends on your previous behaviour in the school. If a girl was well behaved, she will be allowed back … if she was troublesome she is asked to try other schools. FGD, in-school young women aged 20−24 years, Mahlangatja

Re-entry is not easy, especially when you dropped out because of pregnancy, you have to go to another school … The only time when you are able to return to the same school is when you dropped out due to lack of tuition fees. FGD, out-of-school young women aged 20−24 years, Mahlangatja

96 Ministry of Education and Training, 2016. Annual Education Census (AEC) Report 2016 Education Statistics. 97 Ministry of Education and Training, 2018. National Education and Training Sector Policy 2018. 35 GEOGRAPHIC AND PROGRAMMATIC SCOPING OF AGYW IN 3 TINKHUNDLA

They don’t come back to the same school they were in because of the stigma of being labelled as so and so’s mom. FGD, in-school adolescent girls aged 10−14 years, Mhlume

... they enrol in other schools, especially those impregnated by their teachers. They feel they cannot go back to the same school for fear of victimisation by other teachers. Key informant, Somntongo

We follow the Ministry of Education policy on re-entry which give rights to all students and we support them. Key informant, Mahlangatja

The mixed sentiments on the implementation of the re-entry programme are a cause for concern. There is need for stakeholders and partners programming for AGYW to advocate for implementation of the policy as set out by the Ministry of Education and Training. Implementation of the policy should not be at an individual’s discretion nor vary from school to school or community to community.

10.5 Gender-based Violence Response

Mahlangatja, Mhlume and Somntongo Tinkhundla have an established police station, and also have community police. However, communities reported that the police stations are very far away and one would need money for transport to report a crime. Rape cases are prevalent in the community and members expressed their dissatisfaction with the way reported cases are processed through the judicial system. They noted that some rape offenders are not arrested or when arrested are bailed out and continue to reside in the same community with the rape survivors. The survivors do not feel safe around the community. A key informant in Mahlangatja indicated that the police station has a department that focuses on domestic violence and provides counselling services to abused AGYW.

Survivors of rape and abuse report to the police station. We facilitate them receiving health services at the clinic. Key informant, Mahlangatja Inkhundla

There are rare cases of gender-based violence, those that are reported are of boyfriends beating up their girlfriends. Key informant, Mhlume Inkhundla

Police activities include maintaining peace and security in the community, occasionally visiting schools to provide education on the consequences of alcohol and drug abuse, the different forms of abuse, road safety, crime prevention and the importance of reporting a crime. They also encourage students to report any form of abuse or crime they encounter.

10.6 Civil Society Organizations

Eighteen Civil Society Organizations (CSOs) were identified in Mahlangatja Inkhundla as listed in table 7 below. Those that implement interventions focused on AGYW encompass Bantwana Initiative, Dreams on Wheels, FLAS, Mothers2Mothers, Project Canaan, PSI, World Vision, the National Archives and Taiwan Fund for children. Twelve CSOs were identified in Mhlume Inkhundla namely Pact, Children’s Intervention in Swaziland (CHIPS), SWAGAA, New Start, MTN Foundation, CHAPS, and FLAS (see table 8). In Somntongo, ten CSOs are currently working in the area including Bantwana, World Vision, MSF, FLAS, the Luke Commission, and Gone Rural as presented in table 9. The organizations identified are mainly implementing interventions for in-school AGYW and not for those out of school. The programme to be implemented in the three Tinkhundla will address a gap as it seeks to reach out-of-school AGYW.

36 GEOGRAPHIC AND PROGRAMMATIC SCOPING OF AGYW IN 3 TINKHUNDLA C

Table 7: Civil Society Organizations in Mahlangatja Inkhundla

NAME OF ORGANIZATION INTERVENTION Bantwana Initiative Provide dignity packs to AGYW and school fees for students who cannot afford them. Dreams on Wheels HTS and school bags. ICAP Health services to adolescents and young people: HTS, ART and SRHR. FLAS Life skills and behaviour change education to AGYW; HTC; SRHR using a peer education approach – stepping stones; condom/lubricants promotion and distribution; and as a way of encouraging young people, provides them with E350 for airtime and other requirements for the 3 months of training. Treatment of minor ailments; operate a mobile clinic in the community once in 3 months. Litsemba Letfu Clinic VMCC with ABYM. Luke Commission HIV prevention education including abstinence and condom use. Mothers to Mothers (m2m) Education on prevention of mother-to-child HIV transmission by mentor mothers from the organization. Visited twice a month. MSF Mobile clinic for TB screening, and case management. Clients who test positive are referred to Mankayane Hospital, about 26km away from Mahlangatja. Nazarene Compassionate Skills and self-employment. NERCHA HTS and information sharing and dissemination. Those tested for HIV receive E50. Project Canaan Offers farming, beadwork, and construction employment opportunities to AGYW. PSI Provides food parcels, shoes, medication and school fees for needy AGYW; HIV and AIDS information; VMMC. Red Cross Agricultural programmes and provides a portion of land (plots) for cultivating crops for those who are willing or interested in their programmes. Save the Children Supply food packs to vulnerable households with children under 5 years SKRUM Edutainment − conduct rugby games in the community and condom promotion and distribution. The National Archives Teach cultural activities like the reed dance and Incwala to AGYW. Taiwan Fund for Children Support needy students with school fees. (TFFC) World Vision Provides clothes and food parcels for the needy adolescents.

37 GEOGRAPHIC AND PROGRAMMATIC SCOPING OF AGYW IN 3 TINKHUNDLA

Table 8: Civil Society Organizations in Mhlume Inkhundla

NAME OF ORGANIZATION INTERVENTION Pact VMMC services. Provides education around the importance of circumcision and the actual procedure is offered. Children’s Intervention in Provides HTS and education on STIs and HIV/AIDS related issues, distribute condoms and Comm Swaziland (CHIPS) ART, and provide transport from home to health facility for terminally ill patients. Support PLHIV. SWAGAA Visits schools and provides education promoting behaviour change and HIV prevention measures like the use of condoms and abstinence. New Start Provides HTS to the community; mobile clinic services at bus ranks. MTN Foundation Sends motivational speakers who encourage students. FLAS Life skills education and behaviour change to AGYW. To encourage attendance, FLAS provides airtime to the value of E300 to each participant who would have attended all the sessions. These sessions last for about three months. World Vision Pay for school fees and provide clothes for the needy; mobile clinic. PSI Mobile clinic.

Centre for HIV and AIDS Condom promotion and distribution; teach about living healthy lifestyles, Prevention Studies (CHAPS) VMMC. Soka Uncobe Promote VMMC; provide transport to the clinic for those who want to be circumcised. Monitor their healing process. Blood Bank Come to schools once a year for blood donations.

Table 9: Civil Society Organizations in Somntongo Inkhundla

NAME OF ORGANIZATION INTERVENTION Bantwana Provide dignity packs to AGYW and school fees for students who cannot afford them. World Vision Pays for school fees and buy uniforms for AGYW; Provides dignity packs, blankets and money (about E1,500 (about USD103)). Trains youths to start income-generating projects on rearing indigenous chickens, pig- and bee-keeping. They also provide hives for the bees. Doctors Without Borders Provides HIV testing including self-testing, TB screening and treatment, and ART. Teach about (MSF) food nutrition and HIV/AIDS; condom promotion and distribution once a month. Mobile clinic once a month. FLAS Blood testing; condom promotion and distribution; mobile clinic. Luke Commission Treatment of minor ailments (such as flu, stomach-ache and chicken pox); VMMC for adolescent boys and young men aged 10−40 years. Gone Rural Trains adolescent girls and young women in making grass products that are sold locally and overseas. The women also make hair gel to sell in the local market. PSI HIV testing and counselling services; promotion and distribution of condoms. Mobile clinic. Red Cross HIV self-test kits; support families affected by disasters. North Star Alliance HIV and AIDS prevention, treatment, care and support to sex workers. The Nhlangano AIDS Training Faith-based, provides information, training, testing and counselling on HIV/AIDS; distribute Information and Counselling contraceptives. Center (NATICC) 38 GEOGRAPHIC AND PROGRAMMATIC SCOPING OF AGYW IN 3 TINKHUNDLA C

11. Economic Empowerment Programmes for AGYW

Objective 2: Assess existence of income-generating projects/initiatives involving AGYW

Objective 3: Determine social/economic engagements of AGYWs (what occupies their time)

There are limited employment opportunities in the community besides working in fields. FGD, parents, Mahlangatja Inkhundla

In Mahlangatja, the Government of the Kingdom of Eswatini has provided a vocational training centre known as the Rural Education Centre where young people are trained in any one of these courses: dressmaking, boiler maker, computer skills, wiring skills and catering, baking and selling. The community indicated that young people fail to access the trainings due to lack of funds for school fees and look to the government for sponsorship. There is an avenue here for linkages and partnerships in economic empowerment programming activities for AGYW.

In the past, the European Union brought staff from Manzini Industrial Training Centre (MITC) to the community to train young people in welding. After the training, it is reported that the young people trained could not start their own work activity due to lack of start-up kits and a place to operate from.

In Mahlangatja, most young people work in gardens and dagga fields where they receive E50 per day, while AGYW are employed as child minders or domestic workers. Unemployed male youth spend their time playing cards in local shops and play soccer, while females only do household chores in their respective homes.

The common employment opportunities for adolescent girls and young women in Mhlume Inkhundla are working in the local grocery shops, salons and restaurants on weekends and school holidays. The jobs include cleaning, packing of goods onto shelves, minding babies, doing laundry for people, selling fruit and vegetable, working in mango fields, and weeding in the sugarcane fields where they earn about E1,000 per season as casual workers.

The people in the community also plant gardens on vacant land that they rent from the farm owners at about E1,000 per season for 1 hectare. Not many people engage in the planting of gardens because they lack capital to start the projects and are reluctant to form groups of 10 to benefit from the Inkhundla fund.

The youth, mostly boys, spend much of their time around local shops and playing soccer due to the unavailability of employment. This idleness also results in them engaging in risky behaviour like sex and drug and alcohol abuse.

In Somntongo, AGYW are mostly employed at the textile factories in Matsanjeni where they are paid E1,200 per month. The money is not enough for them to live on because, as they also work on night shifts, they have to rent flats near to the factories. A standard flat is about E400 per month and they still have to send some money home to support their children with their mothers. A small percentage of the girls work in the maize and vegetable gardens in the community.

Other common activities that AGYW engage in across the three Tinkhundla include buying and selling; waiting on tables in restaurants; baking and selling of scones and biscuits; hair braiding in salons; running mini markets selling vegetables.

39 GEOGRAPHIC AND PROGRAMMATIC SCOPING OF AGYW IN 3 TINKHUNDLA

AGYW Mobility AnnexesThe rate of mobility in Mahlangatja and Mhlume is not high as most young people stay in the community for long periods of time undertaking different self-sustaining activities such as gardening, baking and selling or tending their parents’ cattle. However, on completing their education, some adolescents and young people relocate to Matsapha which has better employment opportunities (for example in the textile industry) compared to Mahlangatja. Some migrate to South Africa to the textile area called Newcastle where salaries are higher than local ones. Mobility of AGYW was noted as high in Somntongo as they seek better employment prospects in Matsanjeni and Nhlangano. 12. Community Structures and Systems for HIV Prevention among AGYW

Objective 4: Assess the extent to which there is a community support system that enables AGYWs to access HIV- and SRH-related services.

Among the community structures in place to support children, adolescents and young people, including AGYW, are: Rural Health Motivators, Community Police, Community Health Workers, and Child Protectors (Lihlombelekukhalela) who were identified in the three Tinkhundla. Child Protectors attend to cases of violence and abuse and oversee the overall protection of children in the community. Identified cases of child abuse and violence are reported to the police. Rural Health Motivators (Bagcugcuteli), on the other hand, visit homesteads and make reports on the living conditions of the community, educate people on HIV and AIDS including treatment adherence, promote and distribute condoms, and identify vulnerable households which should receive food support. They also promote and distribute condoms and offer counselling services on various health-related matters.

The community police are responsible for crime prevention in the community, sensitisation on crime and reporting, educating youth in school on violence and sexual abuse, and promoting peace and security. In Somntongo, the Banakeleli offer counselling to sexually abused children or children abused emotionally and physically, and also provide home-based care to the sick.

Most Youth Clubs identified in the three Tinkhundla are Teens and Social Clubs for in-school adolescents and young people. The Youth Clubs acknowledged are, for example, the Sisterhood Club where students receive information on diverse health-related topics that include HIV and AIDS, teenage pregnancy, and STIs. There are also the Girls in Power Clubs where members are taught business and empowerment skills; and the Junior Achievers Club, mainly for students undertaking commercial subjects. None of the established Youth Clubs were engaging out-of-school youth, an area that programming needs to focus on to reduce idle time for youth.

The scoping assignment also sought to identify the most significant people in the community who could be used as entry points for programme buy-in. These are summarised in Table 10.

40 GEOGRAPHIC AND PROGRAMMATIC SCOPING OF AGYW IN 3 TINKHUNDLA C

Table 10: Most Significant People for Community Support

MAHLANGATJA MHLUME SOMNTHONGO • Rural health motivators • Advocates for behaviour change • Community mobilisers • Indvunasgodzi • Women who accompany young girls • Rural health motivators • Bucopho for the reed dance • Community police • Sports and Recreation Unit • Community leaders (e.g. religious leaders) • Those who have worked as volunteers before

41 CHALLENGES D. CHALLENGES

13. Challenges/Gaps 13.1 Overall

f Out-of-school AGYW are difficult to reach compared to those in-school who are in a controlled environment. Those beyond the school environment perceive interventions that provide information as inadequate, as they always ask ‘What do I get’. Attached to information dissemination they expect a complementary package to with tangible benefits. f Addressing sexual and gender-based violence is still a challenge due to the multifaceted nature of violence which can occur at home, in the community or at school. This is coupled with low reporting of cases. f There are no community radio stations that can address specific issues affecting communities. At national level, all health programmes to be aired on radio depend on two slots open for the Ministry of Health. Time allocated for health programmes, and specifically for HIV and AIDS is not adequate. Currently there is no programme that appeals to adolescents and young people. f Not all adolescent girls in need of educational support are receiving assistance with school fees. This causes high rates of drop-out due to failure to pay school fees at secondary level. f The cut-off age for OVC support for PEPFAR funding is 17 years, yet there are older girls and young women who need such support. The 17 year-old cut-off is a programme requirement but leaves out other girls and young women in need of support, as highlighted by the communities. f There is no context-specific programming as most interventions adopt a blanket approach. Different contexts are not taken into consideration and programming does not adopt suitablet approach to service provision in line with community requirements. f GF and PEPFAR funded programmes are mapped but others are open to possible duplication and overlaps in service provision as partners do not know who is implementing what and where. f Resources are inadequate for HIV prevention initiatives, especially social behaviour-change communication. f Insufficient and weak monitoring and evaluation systems do not fully track intervention coverage, effectiveness and impact.

42 CHALLENGES D

13.2 Constraints Faced by AGYW f Poverty: The World Bank noted that three in four citizens live in rural areas making agriculture their main source of livelihood. As a result, the adverse weather conditions have limited poverty reduction, with the poverty rate at the international extreme poverty line of USD 1.9 per day in 2015.98 Parents live in poverty and are unable to provide adequately for their families. They cannot afford to pay for school fees and children end up dropping out of school. f Lack of employment opportunities: As discussed above, there are limited formal employment opportunities for AGYW who are out of school. Most opportunities are seasonal employment in farming fields, informal sector economic activities such as vending, and domestic activities such as baby minding and laundry. f Stigma and discrimination are still high in Eswatini and AGYW are afraid of testing for HIV due to the stigma associated with an HIV positive status. f Access to services: Barriers and challenges that girls and young women face in accessing care and treatment and prevention services and commodities in the community include the distance of clinics from some communities, thus requiring money for transport to and from the services. Coupled with this is the issue of lack of privacy at the clinic both structurally and at a personal level. As health-care staff are often part of the community, there is no assurance of confidentiality regarding personal information. f Abuse and violence: Some AGYW suffer abuse within the family and the cases are never reported. The survivors of rape are affected for the rest of their lives. f Cultural beliefs: Some families do not believe in modern medical treatment and prefer seeking assistance from traditional healers. AGYW born in such families will likewise not seek modern medical services. f Inadequate support: Young mothers do not have adequate support for themselves and for their babies, including day-to-day upkeep for both mother and child, and birth registration. f Health service providers’ attitude: Nurses exhibit negative attitudes and are judgmental towards adolescents and young women. This attitude can discourage them to the extent that they forego receipt of health services. f Inadequate communication with parents on health issues: There is limited communication between AGYW and their parents/guardians on health issues as AGYW are unable to discuss HIV and AIDS, sex, pregnancy and health-related issues with them. Some AGYW in Mahlangatja highlighted that they find it difficult to discuss health issues with their parents or guardians.

...[We are] afraid to speak to our parents about sex related issues. Therefore, we end up making mistakes... FGD, in-school young women aged 20−24 years in Mahlangatja Inkhundla

98 http://pubdocs.worldbank.org/en/864711477329277290/mpo-am16-swz.pdf 43 RECOMMENDATIONS

13.3 Challenges Faced by ABYM

Drug and substance abuse: As discussed above, drug and substance abuse are prevalent in the three Tinkhundla. A number of community members own dagga fields and most youth work in the fields to earn a living. Adolescent boys start smoking dagga and drinking alcohol at an early age because they can easily access it.

Unemployment: There are limited employment prospects in the three Tinkhundla. This is worsened by the lack of skills development for youth to become employable.

We need a skills development programme, and financial support to start small businesses. FGD, out-of-school young men aged 20−24 years in Mhlume Inkhundla.

FGD, young men aged 20–24 years, Mgidzangcunu Community, Mhlume Inkhundla

Limited participation in interventions: Most adolescent boys and young men do not test for HIV and do not believe in circumcision. They are afraid to take an HIV test fearing a positive status and the stigma and discrimination associated with it. Some boys and young men from Mahlangatja do not believe in circumcision and therefore they do not attend any sessions in relation to VMMC. However, in Mahlangatja there is the Litsemba Letfu Clinic and PSI who implement VMMC activities to reach adolescent boys and young men with information on the benefits of VMMC and convince them to be circumcised.

Out-of-school adolescents and young men expressed their displeasure on being left out of some interventions. For example, they acknowledged that the deworming exercise is for in-school adolescents and young people, but the programme does not find ways of reaching the out-of-school with such services. Secondly, adolescent boys and young men noted that they felt left out as most interventions focus on girls and not boys. The two quotations below capture these sentiments.

Services are being provided in schools and those out of school are not receiving any service. For example, the deworming programme is just for those in school. FGD, out-of- school young men aged 20−24 years in Mhlume Inkhundla

We feel neglected because most services rendered focus on the girl child rather than boys. FGD, in-school young men aged 20−24 years in Mhlume Inkhundla

44 RECOMMENDATIONS E RECOMMENDATIONS E.

Government

f Strengthen private-public partnerships and identify livelihood and entrepreneurial activities that address the underlying causes of AGYW vulnerabilities, for their socioeconomic empowerment. Programmes being implemented need to strengthen economic empowerment programming by investing in vocational training and entrepreneurship, financial support for trainings, and provision of start-up kits. f Invest in strengthening the capacity and meaningful participation of AGYW to amplify their voices and to be agents for change through role modelling and as ambassadors/champions. f Advocacy for increased awareness and reporting, and elimination of violence and for the judicial system to respond adequately to the issues of violence. Advocacy and dissemination of the Sexual Offences and Domestic Violence Act 2018 will address SGBV which is prevalent in the country, with some cases going un-reported. f Disaggregate AYSRH data by sex and age and, through analysis, provide a clearer picture on the situation of adolescent girls and young women. f Increase awareness of teachers, the student board, and the community on the importance of school re-entry for adolescent girls and young women to address negative attitudes towards the practice and fight stigma, including self-stigma, for the returning students. Findings of this assessment suggest that schools use their discretion to allow or to refuse a re-entrant dependent on the reason for dropping out. This can be done through refresher courses and in-service training. f Increase resources for HIV prevention activities as they complement treatment initiatives through awareness and demand creation. Of late, non-biomedical HIV prevention activities have not been receiving a lot of funding in comparison with biomedical activities yet there is a complementary role in terms of social and community mobilisation and demand creation for increased access to SRH, and HIV and AIDS services. f Create adequate space conducive to privacy when people, especially AGYW, are receiving health services at the clinic through structural development/renovation of clinics. AGYW indicated that the lack of privacy at clinics is one of the reasons they do not access SRG, HIV and AIDS services. f Enhance training and education of health-care workers on youth-friendly service provision to remove prejudice, negative attitudes and judgmental tendencies when providing SRH, HIV and AIDS services to AGYW. Negative attitudes of health service providers against AGYW has been documented before, and the same findings in this assessment should heighten the need to address the issue. f Address/remove corporal punishment in schools as it was cited as one of the reasons adolescents and young people drop out of school. f Scale up provision of PrEP services as a follow-up to the successful demonstrations and pilot projects.

45 RECOMMENDATIONS

Implementing Partners

f Include economic empowerment and self-sustaining activities in programmes targeting AGYW for the improvement of their livelihoods and for programme sustainability. f Develop interventions targeting parents to increase their participation in matters that affect the welfare of their children (at home, in school, at church) and instil parenting responsibilities through parent-child communication approaches and community intergenerational dialogues. f Complement government efforts to keep AGYW in school by providing educational support to vulnerable AGYW especially for secondary school education (school fees; transport vouchers and other basic necessities). Studies have shown that keeping girls in school delays sexual debut, early pregnancy and marriage. f Increase awareness on multiple concurrent partnerships, condom use, SGBV, HIV testing, teenage pregnancies, child and early marriage, re-entry into school, health-seeking behaviours, and create demand for services such as HTS and VMMC. f Empower AGYW through training and awareness sessions in negotiation and assertiveness skills. f Utilise an integrated and multi-sectoral approach to layer service provision so as to avoid duplication of efforts and overlaps in programme implementation and service provision. The number of implementing partners and CBOs in the three Tinkhundla are varied and many by any standard and should complement each other in providing services that target the same beneficiary (18 in Mahlangatja; 12 in Mhlume; and 10 in Somntongo). f Implementing partners should reach out to the three Tinkhundla and improve engagement of adolescent boys and young men for HIV prevention, VMMC, reduction of drug and substance abuse, and prevention of violence.

46 RECOMMENDATIONS E

ANNEXES Annex 1. Documents Reviewed

1. African Union Commission, 2015. Agenda 2063: The Africa We Want. 2. African Union Commission, 2013. Campaign to End Child Marriage in Africa: Call To Action 2013. 3. African Union Commission, 2016. ‘Catalytic Framework to End Aids, TB and Eliminate Malaria in Africa by 2030’, Working Group of the Specialised Technical Committee on Health, Population and Drug Control, Experts Meeting 25 to 26 April 2016; Addis Ababa Ministers of Health Meeting Geneva, 21 May 2016. 4. The African Union Commission, Maputo Plan of Action 2016−2030 for the Operationalisation of the Continental Policy Framework for Sexual and Reproductive Health and Rights. 5. African Union: Targets and Milestones to End AIDS, TB and Malaria by 2030. 6. Central Statistical Office, 2017. The 2017 Population and Housing Census Preliminary Results 7. Central Statistical Office and UNICEF, 2016. ‘Eswatini Multiple Indicator Cluster Survey 2014: Final Report’. Mbabane, Eswatini, Central Statistical Office and UNICEF. 8. Cluver, L., 2011. ‘Children of the AIDS Pandemic’, Nature, 2011, 2:474, 27−9. 9. Deputy Prime Minister’s Office (DPMO) − Department of Gender and Family Issues, University of Edinburgh, University of Eswatini and the United Nations Children’s Fund (UNICEF), 2016. ‘National Study on the Drivers of Violence Affecting Children in Eswatini’, Mbabane, UNICEF Eswatini. 10. Detailed PEPFAR Activities for Country Operational Plan, 17. 11. Eswatini: Ready, Resourceful, Risk Aware (Triple R) (locally named Insika ya Kusasa), April 2018. 12. Eswatini TB/HIV Funding Request to the Global Fund: Matching Funds, 28 August 2017. 13. Eswatini TB/HIV Funding Note, 20 August 2017. 14. Eswatini ‘National Youth Policy, 2009’. 15. Eswatini TB/HIV Funding Request 16. Government of the Kingdom of Eswatini, 2018. Eswatini HIV and AIDS Annual Report to Southern Africa Development Community, 2017/18. 1 7. Government of the Kingdom of Eswatini, 2018. ‘National MultiSectoral HIV and AIDS Strategic Framework 2018–2022’. 18. Government of the Kingdom of Eswatini, 2018. National Education and Training Sector Policy, Ministry of Education and Training. 19. Government of the Kingdom of Eswatini, 2018. HIV Self-Testing: Standard Operations Procedure for the Delivery of HIV Self-Testing Services In Eswatini. 20. Government of the Kingdom of Eswatini, 2017. Eswatini HIV Incidence Measurement Survey 2: A Population- Based HIV Impact Assessment − SHIMS2, 2016–2017. 21. Government of the Kingdom of Eswatini, 2016. National Surveillance System on Violence in Eswatini, Annual Report for the year ended 2016. 22. Government of the Kingdom of Eswatini, 2012. National HIV Prevention Policy. 23. Government of the Kingdom of Eswatini, 2012. Children’s Protection and Welfare Act, 2012 (Act No. 6 of 2012).

47 RECOMMENDATIONS

24. Ministry of Education and Training, 2018. National Education and Training Sector Policy 2018. 25. Ministry of Education and Training, 2016. Annual Education Census (AEC) Report 2016: Education Statistics. 26. Ministry of Education and Training, 2011. Inqaba Implementation Manual. 27. Ministry of Health, 2017. HIV 2017 Annual Programme Report. 28. Ministry of Health, 2014. The Second National Health Sector Strategic Plan 2014−2018. 29. Ministry of Health, 2013. National Policy on Sexual and Reproductive Health. 30. National Surveillance System on Violence, 2017. January–June 2017 Bulletin. 31. PEPFAR, Eswatini Country Operational Plan, 2018. Strategic Direction Summary, 15 March, 2018. 32. PEPFAR Country Operational Plan, 2018. ‘Vision Eswatini’, (Internal Use Only), 2018. Regional Planning Meeting, 19 February, 2018. 33. Regional Psychosocial Support Initiative (REPSSI), 2016. Resourcing Resilience: The Case of Social Protection for HIV Positive Children on ART in Eastern and Southern Africa. 34. Regional Inter-Agency Task Team on Children Affected by AIDS (RIATT-ESA), 2015. Intensify HIV Prevention and Treatment for Adolescents. 35. Southern Africa Development Community (SADC), 2017. SADC Integrated HIV, SRH, TB and Malaria Strategy and Business Plan, 2016−2020. 36. Southern Africa Development Community, 2015. Regional Indicative Strategic Development Plan 2015−2020. SADC Declaration on Youth Development and Empowerment. 37. Southern Africa Development Community, 2015. Minimum Package for HIV and SRH Integration in the SADC Region. 38. Southern Africa Development Community, 2009. Policy Framework for Population Mobility and Communicable Diseases in the SADC Region. 39. Southern Africa Development Community, 2003. ‘Maseru Declaration on the Fight against HIV/AIDS in the SADC Region (2003)’. 40. Southern Africa Development Community, 1999. SADC Protocol on Health. 41. United Nations, 2015. The Global Strategy for Women’s, Children’s and Adolescents’ Health (2016−2030). 42. United Nations, 2015. Sustainable Development Goals, available at: https://www.undp.org/content/undp/en/ home/sustainable-development-goals.html. 43. United Nations, 2014. 90-90-90: An ambitious treatment target to help end the AIDS epidemic targets, available at: https://www.unaids.org/sites/default/files/media_asset/90-90-90_en.pdfUnited Nations, 1989. Convention on the Rights of the Child, 20 November 1989. 44. UNAIDS Data, 2018, available at: https://www.unaids.org/sites/default/files/media_asset/unaids-data-2018_ en.pdf 45. UNAIDS, 2018. Global AIDS Update: “Miles to Go”. 46. UNAIDS, 2018. Fact Sheet – Latest statistics on status of the epidemic. 47. UNAIDS, 2015. UNAIDS Gap Report. 48. United Nations Department of Economic and Social Affairs (DESA), 2013. Inequality Matters: Report on the World Social Situation 2013. 49. UNAIDS, 2013. Ministerial Commitment on comprehensive sexuality education and sexual and reproductive health services for adolescents and young people in Eastern and Southern African (ESA). 6−7 December 2013, Cape Town, South Africa.

48 RECOMMENDATIONS E

50. UNGASS, 2016. Political Declaration on HIV and AIDS: On the Fast Track to Accelerating the Fight against HIV and to Ending the AIDS Epidemic by 2030. 51. UNICEF, 2018. Data: Infants HIV Testing 2017. 52. UNICEF, 2017. Social Protection Budget Eswatini 2017/2018. 53. UNICEF Eastern and Southern Africa, 2015. Regional Analysis Report. 54. UNICEF Annual Report 2015. 55. UNICEF national population-based surveys in Eswatini, Kenya, Malawi, Tanzania and Zimbabwe. 56. UNICEF, Centers for Disease Control (CDC) and Muhimbili University for Health and Allied Sciences. 2011. Violence against Children in Tanzania. Findings from a National Survey, 2009. 57. WHO, 2015. Global Health Sector Strategies on HIV, Viral Hepatitis and Sexually Transmitted Infections (STIs), 2016-2021. Briefing Note: October 2015. 58. World Education’s Bantwana Initiative in Eswatini. 59. World Bank, 2015. Swaziland. http://pubdocs.worldbank.org/en/864711477329277290/mpo-am16-swz.pdf 60. Zungu-Dirwayi, N., et.al., 2004. An Audit of HIV/AIDS Policies in Botswana, Eswatini, Lesotho, Mozambique, South Africa, and Zimbabwe. 61. https://www.unicef.org/esaro/7310_Gender_and_PMTCT.html 62. https://www.unicef.org/esaro/5482_HIV_AIDS.html 63. https://www.unicef.org/esaro/5482_HIV_prevention.html 64. http://esaro.unfpa.org/en/topics/child-marriage 65. https://www.unicef.org/esaro/5480_violence-against-children.html 66. https://www.unicef.org/esaro/5480_violence-against-children.html 67. http://www.unaids.org/sites/default/files/media_asset/Stay_free_vision_mission_En.pdf 68. https://www.prepwatch.org/Eswatini-close-up/ 69. http://www.swagaa.org.sz/

49 RECOMMENDATIONS

Annex 2: List of Key Respondents

NAME DESIGNATION MINISTRY/ORGANIZATION Zandile Masangane ASRH Focal Person Ministry of Health Deputy Prime Minister’s office Sandile Ndzimandze Social Worker (Department of Social Welfare) HIV and Health Education National Edwin Simelane UNESCO / Ministry of Education Programme Officer Muziwethu P. Nkambule HIV Prevention Manager NERCHA Nqobile Tsabedze Director Grants Management Unit CANGO Wendy Benzerga Lead Prevention Programme USAID/PEPFAR Silke Felton Deputy Country Director Leonard Kamugisha Chief, Adolescents and Youth Development UNICEF Nicole Miller Country Director PACT Philile Malindzisa Youth Affairs Manager FLAS Siphiwe Nkambule Director Super Buddies Tom Churchyard Executive Director Kwakha Indvodza

Hlobisile Motsa Executive Director Lusweti Institute for Health Development Thwala Phetsile Programme Officer Communication

Mahlangatja Inkundla Sicelo Simelane Inkhundla Secretary Ekuphakameni Mfanzile Lucas Maseko Community Headman Ekuphakameni Mellicia Dlamini Guidance & Counselling Teacher Zamani High School Jabu Simelane Guidance & Counselling Teacher Sigcineni High School Mavis Mndebele Sister in Charge Sibovu/Mahlangatja Clinic Velaphi Simelane Staff Nurse Police Officer Mankayane Police Station Rural Health Motivator Community Tholelani Mndzebele Church Leader Community Nobuhle Mndzebele Mother 2 Mother FGD with AG 10-14 years Students FGD with AG 15-19 years Students FGD with YW 20-24 years Students Sigcineni High School FGD with YM 20-24 years Students FGD with AG 10-14 years Students

50 RECOMMENDATIONS E

NAME DESIGNATION MINISTRY/ORGANIZATION

FGD with AG 15-19 years Students Zamani High School FGD with YM 20-24 years Students FGD with YW 20-24 years Out of School FGD with YM 20-24 years Out of School Community FGD with parents Community members

MhlumeInkundla JabulaneTsabedze InkhundlaBucopho Tshaneni Tina Mamba Sister-in-charge Vuvulane Clinic Joice Hlandze Teacher Ngomane High School Rev Mvelase Nkomo Church Leader Mgidzangcunu Betty Vilakati Rural Health Motivator Vuvulane FGD with AG 10-14 years Students FGD with AG 15-19 years Students Lusoti High School FGD with YW 20-24 years Students FGD with YM 20-24 years Students FGD with AG 15-19 years Students Ngomane High School FGD with YW 20-24 years Out of School Tshaneni FGD with YW 20-24 years Out of School FGD with YM 20-24 years Out of School Vuvulane/Mgidzangcunu FGD with Parents Community members

Somntogo Inkhundla Nokuthula Sikhondze Inkhundla Secretary Vimbizibuko Cythia D. Dlamini Teacher Ezindwndweni High School Betrinah Hlophe Nurse Matsenjeni Health Centre Zweli Tfwala Police Officer Somntongo Community Phumzile Malaza Church Leader Vimbizibuko Community Sphiwe Motsa Rural Health Motivator Mgampondo FGD with AG 15-19 years Students Ezindwndweni High School FGD with YM 20-24 years Students Ezindwendweni High School

FGD with YW 20-24 years Out of school Vimbizibuko Community FGD with YM 20-24 years Out of school

51 RECOMMENDATIONS

Annex 3: Mahlangatja Clinic Checklist

HIV PREVENTION AND TREATMENT FOR AGYW YES NO COMMENTS/ADDITIONAL INFORMATION (PROBE FOR STOCKOUTS) Availability of SRH services  Availability of condoms (M; F)  Both males and female condoms Availability of HIV Test Kits  Availability of STI testing  Voluntary Medical Male Circumcision (VMMC) being  With PSI and Litsemba Letfu by arrangement carried out (probe for uptake, key challenges and suggested solutions) Availability of medicines for treatment of STI  Availability of safe blood for transfusion  Blood samples for testing are taken to Mbabane/ Mankayane Hospital Availability of a Youth Friendly corner  Availability of ARVs  Available CD4 machines  Mankayane Hospital Available chemistry analyser  Available test reagents  Availability of TB sputum test  Availability of PrEP  We have not used it this far Staffing Number of cadres certified to perform rapid HIV testing  ICAP/Teen Group Number of cadres trained in youth-friendly service  ICAP/Teen Group provision Number of peer educators  ICAP/Teen Group Number of PLHIV trained and participating as peer  Monthly reports counsellors and community mobilizers Is there adequate and skilled staff (laboratory, nurses,  pharmacists)

52 BACKGROUNDRECOMMENDATIONS AND CONTEXT A