HIV in Swaziland through the eyes of a PCV

I am going to start this post with explaining a little about HIV and HIV in Swaziland. Before moving here I had a general understanding of HIV transmission but through training I have increased my knowledge. I would like to share some of that information so that we can all have at least a familiarity with HIV and in particular, HIV in Swaziland. I have mentioned in at least one previous post that Swaziland has the highest rate of HIV in the world. Hearing that statistic and seeing it are two very different experiences. When I heard that Swaziland had the highest rate of HIV in the world at 31% I was concerned, sad, nervous, and maybe even scared that I wouldn’t know what to do or say. Now, living here my main feelings toward the statistic and the discussion around in are frustration and determination.

HIV is an infection that is transmitted human to human (it cannot be passed from a mosquito or an animal) through bodily fluids such as blood, semen, breast milk, and vaginal fluids. There is no evidence that HIV can be spread through saliva. Once in the body HIV attaches itself to the bodies CD4 cells (formerly known as t-cells). The HIV then injects it’s RNA into the CD4 cell and converts to DNA. An infected CD4 cell can reproduce up to 10,000 HIV copies before that cells dies. Each new copy of an infected CD4 cell will continue to infect other CD4 cells. Essentially HIV becomes apart of the person’s DNA. There currently is no cure for HIV. HIV is treated using ART or Antiretroviral Therapy (also known as ARVs). The body can build resistance to ARVs so doctors prescribe three drugs at a time. The first three ARVs prescribed become the 1st line to fight the infection. If the body builds resistance then doctors will move to a 2nd line with three new ARVs. There are 1st, 2nd and 3rd line ARVs produced in the world. Some of these drugs are incredibly expensive and therefore only available in some countries. In Swaziland there is no 3rd line treatment because it is too expensive. So in the country with the highest rate of HIV in the world there are only two lines of treatment. Worse is that if an infant tests positive for HIV and has a positive mother taking ARVs the baby is already resistant to the 1st line ARVs and has to begin treatment with the 2nd line ARVs. If the child’s HIV becomes resistant to the 2nd line ARVs there is no 3rd line option available in the country. This child will have no treatment options past these 2nd line drugs. Now, onto the understanding of HIV in Swaziland.

I am not typically outgoing person. When I am out in public I will say hello to someone but I have to push myself out of my comfort zone to start conversations. That’s not always needed here because people tend to want to talk to the umlungu (white person) so they start the conversations for me. As I mentioned in the last post I live between two towns so when I want to get into town I wait on the side of the road and when transport is coming I point in the direction I want to go. I wait at the same spot each time I go to town but I have never waited with the same people, yet. I have had discussions while waiting for transport, after only exchanging a greeting and names with the person, about HIV testing and condom use. This is something I never would imagine happening in the United States but here it’s actually quite common.

I came to Swaziland wondering how I was going to approach these types of conversations. I have never been in a position where I need to ask people that I have just met if they have considered testing for HIV or if they know there status. I haven’t had to ask people about whether they regularly use condoms and if they don’t, what’s the reason behind that decision. Here I am expected to do that and the funny thing is it is actually a lot easier than I ever expected.

Swazis know that the country has the highest rate of HIV in the world. There are some Swazis who believe in a conspiracy theory that the rate is inflated in order to get additional aid from other countries but there are few supporters to this theory. Here there are billboards, signs, painted garbage cans, murals and even what looks like graffiti all presenting messages about either condom use, testing, monogamous relationships or all of the above at the same time. One billboard that has stuck with me said, “Cheating? Use a condom. Cheated on? Get tested.” When I saw this sign the first time I was incredibly frustrated. I read it and instantly thought that the creator was supporting cheating. Thinking over it again I actually appreciate this message more now. The creator is acknowledge that cheating will happen, not that it should but that it will and because of this fact, people need to work on protecting themselves. The message isn’t “You can have more than one partner and be worry free!” Instead the message is “Multiple partners is risky so make sure you are protecting yourself.”

I have been here just over three months and I have actually lost count of the amount of times I have discussed HIV testing or condom use with someone I have just met. Now back to my story about waiting for transport and my discussion there. One day I was waiting to go into my shopping town and I met a man at the bus stop. We exchanged greetings and he asked my name and what country I am from. I then explained I was a Peace Corps volunteer. We didn’t talk for a few minutes and then he just out of the blue asked me if I have ever tested. I am honest when I am asked this question and say yes. I had to get tested before I was able to join the Peace Corps. He told me that he has never tested because he is afraid. He said he wife goes to test every six months and since she is his only partner, when she comes back negative he just assumes he is negative. Now this could be true but they could also be a discordant couple (one person is positive and the other negative) and he could be positive. Knowing a partner’s status is never guarantee that you have the same status. We talked a little more about the fact that not testing is actually worse for your health in the long run because if positive the sooner you start ARVs the better chance you have of controlling your CD4 count and living a healthy life even though you are HIV positive. This message that positive isn’t the end of the world isn’t taught everywhere in the country though. The negativity towards positive testing is incredibly frustrating.

A few weeks ago I attended a church service where the pastor stood up and said he wanted to address “this HIV issues.” This pastor is not a Swazi, he is European, I will not further identify him as to keep this more neutral and information based. He then proceeded to state that condoms are not the answer to the HIV issue in Swaziland but abstaining is the answer. He followed that by asking the people present to think of someone they know with HIV and how sad and sick that person is and how that person becomes a “nuisance” to those who love them. He actually used the word nuisance. That’s the moment that I became incredibly frustrated.

In a country where the HIV rate is 31% with a population just around one million everyone in this country knows and has loved someone that has died due to complications of HIV/AIDS, everyone. That means that the pastor told everyone in the room that their loved one was a nuisance because of their HIV status. This is the exact opposite message that Peace Corps, medical professionals, and other development agencies in the country are trying to send. Testing is encouraged because now with ART someone that tests positive for HIV can live a happy and healthy life as long as they continue to take their ARVs and maintain an otherwise healthy lifestyle. The goal is to acknowledge that HIV is out there but that a positive test doesn’t mean instant painful death. There are even camps in the country for children who have tested positive in order to encourage them to continue taking their ARVs and live healthy lives because that positive diagnosis isn’t the end of their life. These kids can still achieve goals they have set for themselves and live for many healthy years to come because of ART.

I wanted to write this post to give a better explanation of what HIV actually looks like in Swaziland. People in Swaziland receive mixed messages about testing positive for HIV and that needs to stop. It’s not about shaming people or a message of failure. People can’t go back in time and change their status. Shaming does nothing but discourage testing for others. Testing is important. ART is important. Condom use is important. Postponing a person’s age of sexual debut is important. Teaching that multiple partners increase the risk of transmission is important but the most important message we as PCVs can send everyday is that testing positive isn’t the end of a person’s life. Rather it’s the chance to stay happy and healthy for years to come because now the person can get proper medical treatment. 

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