27 Jan 2009 | Article

 

Lushaba mother, on the right, with his three adult children. All are HIV/Aids positive. Themba Lushaba, the second from left, is too sick to go to the clinic. Jonathan Heyer

Was our intervention in Swaziland necessary, and why ask the question? At the MSF- Annual General Meeting in 2007, some people argued that there was absolutely nothing for MSF to do in such a country – a middle-income nation with an organised and functioning health system, which hosts thousands of tourists from around the world, and which (at the time) was enjoying the benefits of the economic boom in neighbouring South Africa. After 9 months in Swaziland, there is no doubt that our intervention was necessary.
In this small landlocked country, between the regional giant South Africa and Mozambique, appearances are deceptive. The first impression is indeed that of a well-managed state with a well-maintained infrastructure and a well-nourished population. But that does not take into account the reality beyond the comfortable context of Ezulwini Valley, the valley of heaven. Indeed,  the picture is not so rosy in this small kingdom. The prevalence of HIV/AIDS in Swaziland’s adult population is the highest in the world (26%), the number of reported cases of tuberculosis is in excess of 1,200 per 100,000 a year, and the rate of HIV/AIDS and tuberculosis co-infection is over 80%. For a country with a population of just 1 million, negative demographic growth and a life expectancy of only 32 years, the future looks rather bleak.

 

Nowadays, there is almost certainly not a single Swazi family that is not affected by the dual epidemic. In rural and peri-urban areas, there is an increasing number of orphans (100,000 have been registered nationwide today – a tenth of the population), households under the responsibility of the elderly or children are commonplace, and the country is deprived of the most economically active (and most sexually active) age group of its population decimated by HIV/AIDS and its opportunistic diseases. Soaring inflation on basic consumer goods and transport costs, and loss of earnings of working-age people who are unfit to work have disastrous consequences for many households whose incomes are already low. In a country where 80% of the population lives in rural areas and the rural habitat is organised into a multitude of small, isolated homesteads, far from the main lines of communication, access to care is difficult for a large number of families.

59% of women between 15 and 49 have never tested and 81% of men in the same age group are in the same situation, according to DHS Survey realised in Swaziland in 2007.
In this context, one might expect to be bombarded with prevention messages at every turn and see screening units on every street corner. But there is nothing of the sort. The country appears to be suffering in silence, under a threatening cloud of stigmatisation.

 

The teams really got down to work in early 2008 in the structures faced with a colossal influx of patients.

 

MSF’s intervention is based around 3 referral health facilities and 19 community clinics located in the Shiselweni region (population 208,454), which are largely managed by the Ministry of Health. We are working in close collaboration with health workers who are often out of their depth (and sometimes indifferent), and not always trained to deal with the challenges of HIV and tuberculosis.

 

Due to a lack of human resources , our progression was gradual during the first 6 months of 2008. MSF gradually decentralised part of the HIV/AIDS and tuberculosis services to the rural clinics (currently 9 of the 19). Our work includes: encouraging the systematic screening of risk patients; providing pre- and post-treatment counselling for patients; collecting blood samples for CD4 testing and spit that allows to screen for tuberculosis; obtaining ARVs for a growing number of decentralised patients in order to save them having to travel to the health centres; training nurses in the treatment of opportunistic diseases. To help them, we have started deploying “expert patients” – people undergoing HIV treatment who participate actively in the care of patients, although their number and role are still rather limited.

 

In this context, it is essential to muck in with local health personnel, helping them care for and treat patients. Upstream, we must convince the national programme of the urgent need to let us start treating patients at the local clinics, which is not yet the case; ensure a constant supply of drugs to the health facilities; push for increased participation and responsibility for expert patients, both within and outside care centres in order to follow up treatment dropouts; set up a real combined approach for the simultaneous treatment of HIV and TB patients at the most decentralised facilities. Because, let there be no mistake, today it is tuberculosis that is wreaking havoc and decimating the weakest members of the population.

 

In order to get the upper hand and start treating patients more quickly, while ensuring that they see through the entire course of treatment, we must remain clear-headed. This ambitious project will require a great deal of time and will require a considerable long-term investment of financial and human resources, in partnership with other key actors in the region and at the other operational centres. The number of cases of tuberculosis continues to rise and resistance to drugs is frequent among migrant populations that easily cross into the neighbouring countries. So there is no doubt about the urgency.