Swaziland is among the countries with the highest HIV prevalence. One of the factors contributing to the high transmission rate of HIV is the mobility of the population. This includes men seeking employment as migrant labourers in South Africa, taxi drivers, soldiers and industrial workers as well as women seeking employment in factories or self-employed as informal traders. Employment opportunities for women are scarce so that women often have to rely on sex work for additional or only income.
Swaziland has adopted the syndromic approach to manage STI in public and private health facilities during the nineteen nineties. Although the principles of syndromic STI management are well understood by most health workers, there is not a coherent system in place with clear, uniform guidelines, reliable supply of drugs and efficient reporting of STI cases and their partners.
While several non-governmental health facilities provide STI services of high standard, a similar standard is not reached in most public health facilities. Of particular concern are the quality of STI services provided by the two main public services in Mbabane and Manzini, where monthly over 1,500 STI patients are treated. This is more than in all other governmental and non-governmental health facilities in Manzini, Mbabane and the immediate border sites together. Staff of these services is committed, but the number of staff allocated is entirely insufficient to adequately handle the patient load considering that each patient should be examined and counselled. Moreover, the staff has apparently not received the necessary training and supportive supervision to ensure an appropriate quality of services. In addition, the clinic space in Manzini is inadequate for STI patient examination.
The laboratory services in Mbabane have the infrastructure and technical capacities to provide the necessary laboratory services for referred STI cases and simple studies on the prevalence of STI in specific population groups. This capacity was confirmed during the successful implementation of the 2001 HIV sero-survey. At present, however, the laboratory is mainly used by the STD clinic of the Mbabane hospital of carry out routine urine test of STI patients with no diagnostic value.
The Municipalities of Mbabane and Mazini have plans to establish municipal clinics that could provide the appropriate infrastructure and staff for STI management. Both municipalities are already involved in outreach programmes for high-risk populations and welcome the cross border initiative. The construction of the municipal clinics in Manzini and Mbabane will take at least another 1-2 years. In the mean time, alternative solutions for STI service provision for the target population should be found.
In Mbabane, the Municipality already provides services for high-risk population at a clinic within the Municipal building. Outreach programmes by FLAS could therefore refer the target population to this clinic. In Manzini the FLAS clinic would currently be the most appropriate facility for referral of the target population. However, the cost of the services at the FLAS clinic is too high for most of the target population. To cover these costs, a system could be introduced whereby FLAS outreach workers and peer educators distribute vouchers to members of the target population requiring services.
The clinics in the border areas of Ngweya and Lavumisa can provide adequate services once issues of drug supply, syndromic reporting and supervision have been addressed. This may require the provision of some security stock of drugs to overcome logistical problems. For all staff involved in the programme, additional training is needed to ensure uniform treatment, counselling practices, and reporting.
Educational materials that are specifically adapted to the different target groups should be produced to facilitate patient management and promote treatment-seeking behaviour and risk reduction. Sufficient quantities of these materials should be produced in order to ensure uninterrupted availability of these materials.
All key informants raised the context of the specific culture in Swaziland as the main obstacle for behavioural change. According to this cultural context, multiple sexual partnerships are considered as the norm for men and monogamy as the norm for women. In this context, women have no power to reduce their risk for STI, including HIV.
Within this cultural context the fact that the number of men and women affected by HIV and AIDS is about equal seems to be to be ignored. Although men have the power within sexual relationships, they are apparently trapped within their perceived cultural role. While many women are eager to change this situation, their influence is very limited. There is therefore an urgent need for men who have realised the situation of HIV/AIDS and have adapted their sexual behaviour accordingly, to speak out in order to influence other men.
Behavioural change communication is likely to be most effective and sustainable when it is implemented within the wider framework of the community. In Ngweya at the Swaziland-South African border a local traditional leader (and former Minister) has initiated a programme to assist women seeking employment. Health staff of the local clinic are also involved in this initiative. Collaboration between RHAP and this initiative may provide a good opportunity to ensure involvement of the target community as well as traditional leaders. In Mbabane, Manzini and possibly Lavumisa, collaboration with the municipalities is likely to provide the required framework for the establishment of sustainable programmes.
Syndromic management of STD and behavioural change communication are probably insufficient to rapidly reduce STD prevalence in the high-risk population, as asymptomatic infections are frequent in both men and women. Presumptive Periodic Treatment could boost the effect of the programme on STI prevalence and could also reduce the incidence of serious complications such as pelvic inflammatory disease.
The introduction of this strategy would require a baseline biological assessment and further biological monitoring, for which links need to be established with laboratories outside the country to carry out specific assays. It should be therefore only considered within an overall action plan to strengthen STI services in the target areas.
Strengthening of syndromic STD management and promotion of safer sex through peer education could entirely be covered through the existing RHAP agreement. For the implementation of Periodic Presumptive Treatment, however, additional resources should be mobilised. Due to USAID restrictions on drug supply, RHAP may have to link-up with other partners to ensure long-term drug supply if this intervention is considered. Regular biological assessments should be considered to be an integral component to monitor the effect of this innovative approach.
Based on the types of interventions that are considered and the available resources, a detailed action plan and budget should be developed with the partners identified.
