Important note: Information in this article was accurate in 2008. The state of the art may have changed since the publication date.
UN Integrated Regional Information Networks - December 3, 2008
A new UNAIDS model for estimating how many people need ARVs has seen the figure for Swaziland almost double from 34,000 to 62,000. In a country where 26 percent of sexually active adults are HIV positive, the new estimate is widely considered to be more realistic, but the new numbers will require the health ministry and non-governmental organisations (NGOs) working in the AIDS sector to devise new strategies to rapidly scale up treatment.
"I am glad we have more realistic numbers to work with," said Anthony Nkambule, an AIDS activist in the country's central Manzini region. "But the reality is shocking, because it shows how far we have to go, immediately, to save lives."
Dr Velephi Okello, the ARV therapy coordinator at Swaziland's National AIDS Programme (SNAP), agreed that the new figure presented a significant challenge to a resource-limited nation like Swaziland.
"All our procurements of drugs and counselling services and distribution systems were based on those initial projections," she told IRIN/PlusNews. "We are trying to be careful about setting expectations, but there's no doubt the ARV rollout must be accelerated."
Hannie Dlamini, founder of the Swaziland AIDS Support Organisation (SASO), the country's first group for people living with HIV/AIDS, said even at the current level of about 30,000 people on ARVs, the government's treatment programme appeared to be under strain.
"There is a shortage of ARVs from time to time, from bottlenecks in the distribution system. People's schedules for taking the drugs are thrown off, and this can make the drugs ineffective for them."
According to Dlamini and local press reports, the government hospital in Mbabane, the capital city's main ARV distribution point, periodically runs out of the drugs.
Last year, 8,000 people - almost a quarter of all patients on ARVs - dropped out of the treatment programme. A health ministry survey found that occasional drug shortages were not the only reason; a lack of health facilities distributing the drugs and inadequate adherence counselling were also obstacles to staying on treatment.
"Distance to hospitals was given as the main reason people became defaulters [stopped taking their drugs]. They either couldn't get to the ARV distribution centres at hospitals in the towns, or they didn't have money for transport," said Okello.
A plan to decentralise drug distribution from a handful of provincial hospitals to 196 clinics across the country is underway. Once patients are considered stable, usually after six months on ARV treatment, they are referred from a hospital to their local clinic.
The Good Shepherd Hospital in Siteki, provincial capital of Lubombo, Swaziland's eastern region, now supports treatment at 15 local clinics. The Raleigh Fitkin Memorial Hospital, in Manzini, supports eight. Mbabane, with only one ARV referral clinic in operation, is lagging.
A system has also been put in place to improve counselling. "Because people test for HIV very late in Swaziland, if at all, we find them in advanced stages of HIV, when their CD4 count [a measure of immune system strength] has deteriorated," Okello said.
"All manner of opportunistic diseases arise, and some patients blame these on the ARVs they are taking, because there is a rumour that ARVs can make you ill. People say, 'These drugs are making me sick,' and they discontinue them."
The government, in partnership with the Swaziland Network of People Living with HIV/AIDS (SWANEPHA), an umbrella body for AIDS support organisations, is training people living with HIV as "expert clients" to counsel those starting ARV treatment about the potential side effects of the drugs and the importance of not interrupting their regimen.
The new initiatives to improve ARV distribution cannot come soon enough. Health officials estimate that by 2009 over 200,000 people, almost a quarter of the population, will be HIV positive and require monitoring; of the 16,700 new HIV infections anticipated in 2009, around 3,000 will be children.
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