The Importance of Behavior Change in the FightAgainst the HIV/AIDS Pandemic in Swaziland

January 2006

The entire nation of Swaziland has become vividly aware of the crisis of HIV/AIDS which is brutally affecting the population.  A typical weekend activity is attending the ever increasing number of funerals.  The government has responded through expanding programs to treat and care for those suffering from the disease, and to continue prevention efforts.

Swaziland suffers from the world’s highest official prevalence of the HIV virus.  According to surveys of pregnant women, an estimated 40% of adults may already be infected.  It is not surprising that some people have reacted to such horrifying statistics with despair and helplessness.  Yet even in such a bleak situation, we must continue to have hope and to work together to reverse this tragic turn of events.  Forty percent prevalence in adults translates to approximately 20% of all Swazis now having the virus.  This means that about 80% of the population has not yet been infected.  It is vitally important – in addition to the absolutely crucial issues of treatment and care – that we all redouble our efforts at preventing new cases of HIV infection.

Even if Swaziland was to be highly successful in expanding access to treatment and care, unless the wave of new infections is curtailed much of the population is doomed to a future of chronic disease, including an ongoing reliance on expensive medications that involve side effects – sometimes significant in nature – in addition to the potential for development of drug resistance and other complications.  Even with access to medication some people will still end up dying from AIDS.  Prevention must remain at the core of our efforts to turn back this terrible disease.

During the late 1980s and early 1990s, Uganda had the world’s highest prevalence of HIV.  The words Uganda and African AIDS were virtually synonymous.  Today Uganda faces the same serious issues as many other African countries in terms of providing treatment for people who are sick from AIDS, caring for the orphans and other affected people, and prevention of mother-to-child transmission.  Yet now the east African nation is doing so within the context of an estimated 4% adult HIV prevalence, not the 20% or worse epidemic that it was on the way to becoming.  HIV prevalence among pregnant women in the capital, Kampala, was at 30% levels in 1992.  Just ten years later HIV was less than 10% in Kampala, and still falling.

How did Uganda so dramatically reverse its crippling AIDS epidemic?  This question has been the subject of numerous studies, publications, and occasionally debate.  But now the controversy over what happened to lower HIV in Uganda has largely culminated in consensus, exemplified by a ground-breaking statement published on the recent World AIDS Day in the leading UK medical journal, The Lancet.  Signed by some 150 international scientific experts, religious and community leaders such as Desmond Tutu, and representatives of the World Health Organization, five United Nations agencies, the World Bank, and the Global Fund for AIDS, TB and Malaria, the statement represents a ringing endorsement of the “ABC” approach so vigorously and successfully promoted in Uganda as well in a small but growing number of other African countries, such as Kenya, Ethiopia and Zambia, that have also brought down HIV to some degree.

While clearly there were multiple factors behind the Ugandan success, as noted in the Lancet consensus statement a key factor, probably the most important one by far, was that a large reduction in multiple partnerships – especially ongoing/overlapping multiple relationships – had occurred.  During the late 1980s and early 1990s, when the rate of new HIV infections evidently made its steepest decline in Uganda, the main messages promoted by the government, churches, media, traditional healers and other key stakeholders were “Zero Grazing” and Love Faithfully,” emphasizing the importance of partner reduction and of sticking to one partner.

While condoms and abstinence also played an important role, it was by directly confronting the pervasive pattern of multiple partnerships that Uganda was able to radically alter the ground in which this sexually transmitted disease had set roots.  The Zero Grazing movement was a fully homegrown African response to AIDS, actively promoted by the national leadership as well as literally thousands of grassroots community organizations, with the country’s churches positioned at the center of prevention.

Other recent studies, several of them also published in leading public health journals, have uncovered similar patterns in a few other African countries where declines in HIV prevalence have been observed.  The 2003 Demographic and Health Survey conducted in Kenya, where HIV prevalence has reduced in recent years, found that while condom use had increased modestly since the 1998 survey, the proportion of both men and women reporting two or more unmarried partners in the previous year declined by about fifty percent, nearly identical to changes reported in similar Ugandan national surveys some ten years earlier.

The Kenyan survey corroborated another striking and still neglected aspect of AIDS in Africa, which is that men who were circumcised had far lower rates of HIV than uncircumcised men.  Dozens of studies worldwide have reported a large difference in HIV between circumcised and uncircumcised men, and between populations who do and do not practice circumcision.  For example, the highest rates of HIV in South Africa are among the Zulus and other non-circumcising groups, whereas lower rates are found in the Eastern Cape and Northern Province, where the tradition of male initiation, including circumcision, remains strong.  Biological studies have discovered that the mucosal tissue in the foreskin provides an unusually attractive magnet for the HIV virus.  There appears to be growing interest among Swazi men – who until about two hundred years ago used to be circumcised – in utilizing clinical services for safe and affordable circumcision.  This could be a positive development, especially if the mistaken belief that just because a man is circumcised he can no longer become infected, is addressed.

In conclusion, while it is vitally important for people to get tested to learn their HIV status, in part so as to access necessary treatment and care services, behavior change must remain at the center of our efforts.  Anti-retroviral medications have been shown to prolong and often dramatically improve the quality of life of AIDS sufferers, yet these drugs are NOT a cure for AIDS.  Only through coming to grips with sexual behavior, especially the tendency to maintain ongoing relationships with more than one person, can we follow the example of Uganda and some other sister African nations, and begin to reverse the horror of HIV/AIDS in our land.  In Swaziland, some religious, women’s, youth and other community-based organizations have been promoting important messages such as abstinence among our youth.  Now we must expand upon this vital message to include a major focus on the need for sexually active adults to stick to one partner, or in the case of polygamy to remain strictly faithful to their marriage partners.