Swaziland is facing a health emergency of immense proportions. According to the World Health Organization, HIV prevalence is the highest in the world, at 25.9 per cent among adults aged 15 to 49, and there are more than 1,250 cases of tuberculosis (TB) per 100,000 people. TB is the leading cause of mortality among people living with HIV and, to make matters worse, cases of drug-resistant TB are increasing: 10 per cent of all TB cases diagnosed are resistant to TB medication. Life expectancy in the country has plummeted over the past two decades – from an average of 60 years to 41 years.

A community-based approach

Swaziland is a rural country of many small, isolated villages. The cost of long and frequent journeys to health facilities is often prohibitive for patients, so Médecins Sans Frontières has developed a decentralised, community-based approach to care. People living in the community have been trained as HIV counsellors and to test for the disease. The aim is to increase the overall number of people being tested, so that more people with HIV can begin treatment earlier. By decentralising care, Médecins Sans Frontières hopes that fewer patients default from their treatment and, in general, patients’ state of health will improve.

Throughout 2010, our team supported all 21 clinics in Shiselweni, the poorest and most remote region in the country. Each of these clinics now provides fully integrated care for HIV/AIDS and TB. Médecins Sans Frontières tested some 14,500 people overall for HIV, tripling the number of tests given each month. The number of people starting antiretroviral (ARV) treatment doubled. More than 2,550 new TB patients began treatment, including over 100 patients infected with drug-resistant TB (DR-TB).  The results of TB treatment, which is a notoriously long and difficult process for the patient, also saw marked improvement.  

Managing DR-TB is a growing challenge. Médecins Sans Frontières  supported the decentralisation of DR-TB care to the three main health facilities in Shiselweni in an effort to improve patients’ access to treatment. A new DR-TB ward with a laboratory is being built, and will be finished in June 2011.

In 2010, Médecins Sans Frontières began a new project in Manzini region, south of the capital, helping Ministry of Health staff to integrate and decentralise TB treatment from the hospital to health centres, and supporting the integration of HIV and TB care in a hospital in the west of the country.  We also started treating DR-TB and supported the national TB programme’s decentralisation of DR-TB services. 

Médecins Sans Frontières has constructed a clinic for comprehensive healthcare, including HIV and TB care, in the town of Matsapha, specifically targeting the working population of this industrial centre. We have also supported services at the National Reference Laboratory.

Staffing crisis

Swaziland is desperately short of doctors, and because of limited resources, not enough nurses are being trained. For Médecins Sans Frontières , the solution is to entrust more tasks and responsibilities to other personnel by training nurses to prescribe medicine or treat cases of uncomplicated, non-resistant TB, for example.

In line with this idea, we have enlisted the support of “expert patients”. These are people living with HIV/AIDS who carry out screening, advise and inform new patients about treatment, and raise awareness of HIV in their communities. In 2010, 80 expert patients were working for Médecins Sans Frontières in Swaziland.

Médecins Sans Frontières has worked in Swaziland since 2007.