"Swaziland must urgently step up its efforts against the dual epidemic"

November 28, 2010

"Swaziland must urgently step up its efforts against the dual epidemic" © Fred Matte/MSF

Present in Swaziland since 2008, MSF has contributed to the decentralisation of HIV/Aids and tuberculosis (TB) treatment. However, the dual epidemic is still far from under control. We evaluate the situation with Aymeric Péguillan, MSF's Head of Mission in Swaziland.

Swaziland occupies a unique place on the world HIV/Aids map. This small landlocked country between South Africa and Mozambique has been more severely affected by the pandemic than any other. At 26%, the proportion of the adult population infected with the virus is the highest in the world. Like the other countries of southern Africa, Swaziland is also faced with a tuberculosis (TB) epidemic. TB is the leading cause of death and, to make matters worse, is becoming increasingly drug resistant and therefore increasingly difficult to treat. There are 1,198 TB sufferers per 100,000 inhabitants, more than 80% of whom are also HIV/Aids carriers.

MSF began its programme in Swaziland in January 2008. The international medical organisation is supporting 21 health facilities in the Shiselweni region, in the south of the country. All of these establishments are under the control of the Ministry of Health. Interview with Aymeric Péguillan, MSF's Head of Mission in Swaziland.

What is MSF's approach in such a critical context?

Aymeric Péguillan: When we arrived on the scene, we knew that we couldn't expect to curb the dual HIV/Aids and TB epidemic without decentralising care. Although Swaziland is a small country, it's mostly rural with countless small, isolated villages. The government set up a TB programme in the 1960s, but until recently it was completely centralised and not adapted to the number of patients which has grown in recent years. Patients had to undertake long and costly journeys in order to receive care. Many of them abandoned their treatment. Things got even worse with the emergence of HIV/Aids, which further weakened sufferers' bodies.

What is the priority? The fight against HIV/Aids or against tuberculosis?

Both at the same time. People co-infected with HIV/Aids and TB can't be treated in two different places. In the clinics and health centres of the Shiselweni region treatment is now integrated and staff are trained accordingly. However, another huge problem is that Swaziland is desperately short of doctors and isn't training enough nurses. For MSF, the solution to this human resources crisis is to entrust more tasks and responsibilities to less qualified personnel. Nurses need to be able to prescribe medicines or start treatments in cases of uncomplicated, non-resistant TB.

Following the same idea of transferring tasks, MSF has enlisted the support of "expert patients". These people, themselves living positively with the Aids virus, carry out screening, advise and inform new patients about the treatments, and raise awareness in their communities about the risks of transmission, access to treatment and preventive measures. There are around 80 expert patients working for MSF. Eventually, we'd like them to be recognised and paid by the Swazi government.

Two and a half years since it began, is the MSF programme bearing fruit?

We haven't achieved all our objectives yet, but through our activities in Shiselweni we've demonstrated that decentralisation of care works. Patients can receive their treatment closer to home. Each community is more involved, and that increases awareness. The transfer of tasks also frees up nursing personnel who can then focus more on clinical work. Far from compromising the quality of care, these measures increase the treatment offer and strengthen local health facilities. But despite this strategy, which has been adopted by the authorities, the government still needs to train staff. There is currently no medical school in Swaziland. Similarly, lab assistants and pharmacists undertake all their training in neighbouring South Africa.

Is Swaziland managing to slow down the dual epidemic?

Unfortunately, there's been no significant reduction in infections, although more people are now receiving treatment. Screening is more systematic and patients are put on treatment earlier. That's important, because the sooner tuberculosis patients are treated, the less contagious they'll be. And the quicker people infected with HIV/Aids receive antiretroviral drugs, the less likely they'll be to develop opportunistic diseases and the longer they'll live.

We must commend the Swazi government, which has decreed a state of emergency against the HIV/Aids epidemic. The same sort of commitment is now needed to tackle the huge emergency posed by TB. Each year, it is estimated that around a thousand people die before receiving treatment.

Despite all these efforts, only a third of the Swazi population know their HIV/Aids status. What's more, many people who urgently need treatment still don't have access to it. The virus especially affects the most active categories of the population. These people must have access to the treatment in order to continue living normally. The country's economic future is at stake here too.

At the start of October, the Global Fund to Fight AIDS, Tuberculosis and Malaria only raised $11 billion, when it was asking for 20 billion for the next three years. What will be the consequences of this for Swaziland?

This year, Swaziland requested $137 million from the Global Fund, a large part of which was earmarked to deal with HIV/Aids. The government will have some very tough choices to make. In some countries, they're already waiting for one patient to die so that they can start treating another. It's as if the countries hardest hit by the pandemic are being punished despite the huge progress that's been made in recent years.

Countries like Swaziland must not be wholly reliant on money from donors. They must reconsider their priorities. African States have promised to dedicate at least 15% of their budgets to health. At 13.7%, Swaziland isn't far off this target, but a country so decimated by the dual epidemic must urgently step up its efforts.

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