48358 Public Disclosure Authorized The Government of National Emergency Council on the Kingdom of Swaziland HIV and AIDS (NERCHA) SWAZILAND HIV Prevention Response and Modes of Transmission Analysis Public Disclosure Authorized Public Disclosure Authorized ! For further information contact: NERCHA, SWAZILAND (National Emergency Response Council on HIV and AIDS) March 2009 P.O. Box 1937 Mbabane, Swaziland Public Disclosure Authorized February 2009 Tel: (+268) 404 1720 / 1703 Fax: (+268) 404 1692 Email: [email protected] www.nercha.org.sz The Global HIV/AIDS Program (GHAP) The World Bank SWAZILAND HIV PREVENTION RESPONSE AND MODES OF TRANSMISSION ANALYSIS Final Report March 2009 Swaziland Study Team Sibusiso Mngadi, Study Coordinator and NERCHA Focal Point Nicole Fraser, Technical Study Leader (GAMET/World Bank) Happiness Mkhatshwa, Prevention Specialist (consultant) Tyrone Lapidos, Epidemiologist (consultant) Thandi Khumalo, Sociologist (consultant) Sanelisiwe Tsela, NERCHA M&E Coordinator Nhlanhla Nhlabatsi, SNAP/MOHSW Helen Odido, UNAIDS M&E Advisor National Emergency Response Council on HIV/AIDS World Bank Glo bal HIV/AIDS Program Global AIDS M&E Team (GAMET) © 2009 National Emergency Response Council on HIV and AIDS (NERCHA) P.O Box 1937 Mbabane, Swaziland All rights reserved. Swaziland HIV Prevention Response and Modes of Transmission Analysis Study Team Sibusiso Mngadia, Nicole Fraser b, Happiness Mkhatshwac, Tyrone Lapidosd, Thandi Khumaloe, Sanelisiwe Tselaf, Nhlanhla Nhlabatsig, Helen Odidoh a Study Coordinator and NERCHA Focal Point b Technical Study Leader (Global AIDS Monitoring and Evaluation Team/World Bank Global HIV/AIDS Program) c Prevention Specialist (consultant) d Epidemiologist (consultant) e Sociologist (consultant) f NERCHA M&E Coordinator g SNAP/MOHSW h UNAIDS M&E Advisor This study, and similar studies in Kenya, Lesotho, Mozambique, Uganda, and Zambia is the outcome of close collaborative by a team in Swaziland, with technical and financial support from the UNAIDS Regional Support Team for Eastern and Southern Africa, UNAIDS Geneva, and the World Bank's Global HIV/AIDS Program (Global AIDS Monitoring and Evaluation Team). The study entailed using existing data and collecting new data to better know the country's HIV epidemic, know the country HIV response and how funding was allocated, so as to improve the HIV response and strengthen prevention based on evidence on what works to prevent new infections. Keywords: Swaziland, HIV, AIDS, epidemiology, epidemic, modes of transmission, incidence, prevalence, prevention, response Know Your Epidemic, Know Your Response, expenditures, synthesis, National Emergency Response Council on HIV and AIDS, UNAIDS, World Bank Correspondence Details: The Director National Emergency Response Council on HIV and AIDS (NERCHA) P.O Box 1937, Mbabane, Swaziland Telephone: (268) 404 1703/8 Fax: (268) 404 1692 E-mail: [email protected] Acknowledgements This synthesis report is the result of a nine month process of collaborative research, analysis and thinking, and the MoT Country Team is highly indebted to the Swaziland Core Team for steering and overseeing the process. The researchers would also like to express their sincere gratitude to the continuous support by the Policy Team which is responsible for translating these research findings into policy and programming. The MoT Country Team is very grateful to all the individuals and organisations that provided information and interviews for the prevention review. Equally, all participants in the Technical Planning Workshop, the Incidence Modelling Workshop and the Synthesis Writing Workshop are thanked for their active participation and input. Special thanks go to the Central Statistics Office and to Macro International, for their assistance with data for the epidemiological analysis and incidence modelling. At the CSO, Ms Isabella Hlope and Ms Rachel Masuku supported the MoT study throughout with discussions and data from the 2006/07 Demographic and Health Survey. Ms Sri Poedjastoeti and Ms Ladys Ortiz (data processing specialist) at Macro were instrumental in providing specially analysed data for modelling purposes. The UNAIDS Regional Support Team for Eastern & Southern Africa and UNAIDS Geneva provided invaluable technical and financial support to the study. Ms. Susan Kasedde, Mr. Mark Colvin and Mr. Saul Johnson played important roles in supporting the study, building capacity in applying the incidence model (M.C.) and advising on the prevention review (S.J.). Ms. Eleanor Gouws in the Geneva Office provided expert advice on using the incidence model. The Global AIDS Monitoring & Evaluation Team of the World Bank provided important technical support and review through Ms. Marelize Gorgens, Jody Zall Kusek and David Wilson. The study team is also grateful to Mr Feng Zhao, World Bank Task Team Leader for Swaziland for his support to the study. This study drew extensively on existing research and routine data and the MoT Country Team is immensely grateful to all the researchers, implementers and study populations who have contributed to this evidence base. Finally, the MoT Country Team would like to thank the Government of Swaziland for its willingness to participate in this study which was implemented concomitantly in Kenya, Lesotho, Mozambique and Uganda and which will help to inform future HIV/AIDS strategic planning and programming for the benefit of these populations. EXECUTIVE SUMMARY Background, study purpose and implementation - NERCHA, MOHSW, UNAIDS and GAMET/World Bank are collaborating in a capacity development process to support an evidence- based review of Swaziland’s epidemiological situation (Know your epidemic, KYE) and the national HIV prevention response (Know your response, KYR). The purpose of this modes of transmission (MoT) study is “to contribute to the ongoing efforts to understand the epidemic and response in Swaziland and thus help the country improve the scope (doing the right kind of activities), relevance (with the right populations) and comprehensiveness (reaching all members of target populations) of HIV prevention efforts”. The process for the KYE was an in-depth review of available epidemiological data from Swaziland and the sub-region, and application of the UNAIDS incidence estimation model. The aim was to determine the epidemiology of new (incident) infections. For the KYR part, data were collected on the policy context for prevention, prevention and prevention activities by implementers, and data from the National AIDS Spending Assessment (NASA) of 2008 were reviewed. In a final step, the KYE and KYR evidence was linked to produce an epidemic, response and policy synthesis with recommendations to improve the HIV prevention response through aligning prevention activities with the evidence on the sources of new infections. The study examined the hypothesis that multiple, concurrent long-term heterosexual relationships, happening in a context of implicitly permissive social norms, gender inequality and economic need, are a key contributor to HIV transmission in Swaziland. Timing of the study - the MoT study took place at an opportune time when Swaziland also was reviewing the second national multisectoral HIV/AIDS strategic plan (2006-2008) and preparing a new National Strategic Framework. The findings of the SDHS 2006-07, the NASA 2008 and the ‘Mapping of the National Minimum Package of HIV Services’ 2008 had just become available, and the MOHSW and NERCHA had established functional monitoring and evaluation (M&E) systems providing routine data. These all provided essential input into the KYE and KYR analyses. Supervision and review - the study was overseen by the MoT Core Team through monthly meetings and progress reports. Dissemination of the findings and their translation into policy and practice is the responsibility of the MoT Policy Team. Coordination and communication were ensured by the Coordinator of Communication & Advocacy of NERCHA and technical leadership was with GAMET/World Bank. The report benefited from several reviews by the Swaziland Core Team, the Policy Team, Swaziland stakeholders, and regional peer reviewers (implementers of other MoT studies in Africa, UNAIDS RST ESA & UNAIDS Geneva, and GAMET/World Bank). Know your Epidemic HIV prevalence levels and trends - with 26% of the adult population infected (SDHS 2006-07), Swaziland’s national HIV prevalence is the highest in the world. This prevalence level results in higher mortality and, combined with labour migration, will produce negative population growth in the foreseeable future. HIV prevalence of pregnant women in most age groups rapidly increased up to 2004 (most dramatically in 25-29 year olds), but a downturn has been seen in the latest sentinel surveillance data; the next round of ANC surveillance data may confirm whether this is a downward trend. The peak in HIV prevalence in 2004 will result in a plateau in AIDS-related deaths of around 12,500 adults and children per year for at least the next four years. As ART coverage improves, AIDS-related deaths are expected to fall considerably, which will result in a stabilisation or even secondary plateau in HIV prevalence (unless HIV incidence dramatically decreases in the next few years). The increase in mortality and slow roll-out of ARVs has drastically affected estimated life expectancy, which is reported to have halved between the 1990s and 2007 (currently at 37 years). v Heterogeneity of the HIV epidemic in Swaziland - although Swaziland is a small country