KINGDOM OF SWAZILAND 8TH HIV SENTINEL SEROSURVEILLANCE REPORT A NATION AT WAR WITH HIV/AIDS MINISTRY OF HEALTH & SOCIAL WELFARE

Transcription

1 KINGDOM OF SWAZILAND MINISTRY OF HEALTH & SOCIAL WELFARE 8TH HIV SENTINEL SEROSURVEILLANCE REPORT A NATION AT WAR WITH HIV/AIDS ministry of health & social welfare swaziland national aids/stds programme mbabane,swaziland december 2002

2 His Majesty, King Mswati III i HIV Yindzaba yetfu sonkhe, asinakelelane, sigcinane.

3 TABLE OF CONTENTS Acronyms and Abbreviations 3 Acknowledgements 4 Executive summary 5 Chapter 1: Introduction 8 Chapter 2: Country profile : Health care system : National response to HIV/AIDS : Key indicators 12 Chapter3: Survey objectives : General objective : Specific objectives 13 Chapter 4: Survey methodology : Sampling procedures Sentinel population Sentinel sites Sample size Sampling procedures and period Data collection instrument Training of field wor kers Survey preparation Data and specimen collection Laboratory procedures HIV testing Hepatitis B surface antigen testing Syphilis testing Recording and transmission of results Laboratory Quality control Supervision of the survey Data entry and analysis Limitation of the study 17 Chapter 5, Results of the sero-surveillance Page Background characteristics Place of residence Age distribution Education status 21

4 5.1.4 Marital status HIV prevalence and trends National HIV prevalence Regional HIV prevalence HIV prevalence by residence HIV prevalence by age HIV prevalence by education HIV prevalence by marital status Syphilis prevalence Syphilis prevalence by national, region and age Syphilis prevalence trends Syphilis Prevalence by HIV sero status Hepatitis B prevalence Hepatitis B prevalence by national, region and age Hepatitis B by sero status 32 Chapter 7. Conclusions and recommendations 33 References 35 Annexes Annex 3: Data Collection Form 363 Tables Table 1: Distribution of ANC respondents by age group and age, 2002 Table 2: Age Distribution of ANC respondents Table 3: Distribution of ANC respondents by educational level, 2002 Table 4: Distribution of ANC respondents by marital status and age, 2002 Table 5: HIV infection trends among ANC respondents, Table 6: HIV infection trends among ANC respondents, Table 7: HIV prevalence among ANC respondents by region,2002 Table 8: HIV infection trends among ANC respondents by region, Table 9: HIV prevalence among ANC respondents by age and residence, 2002 Table 10: HIV infection rates among ANC respondents by age group, 2002 Table 11: HIV prevalence among ANC respondents by age group, Table 12: HIV prevalence among ANC respondents by marital status and age, 2002 Table 13: Syphilis prevalence by age, 2002 Table 14: HIV prevalence RPR status, 2002 Table 15: Hepatitis prevalence by age, 2002 Page 2 Figures Figure 1: Geographical location of HIV sentinel sites in 2002 Figure 2: HIV prevalence among ANC respondents, Figure 3: HIV prevalence rates among ANC respondents by region, 2002 Figure 4: HIV prevalence trends by region, Figure 5:HIV prevalence by residence,(urban/rural), 2002 Figure 6:HIV prevalence by single age from 15 to 30 years among ANC respondents, 2002 Figure 7:HIV prevalence trends by year, Figure 8:HIV prevalence by educational status, 2002 Figure 9:Syphilis prevalence by age, 2002 Figure 10::Syphilis prevalence trends,

5 ACRONYMS AIDS Acquired Immuno Deficiency Syndrome ANC Ante natal Care BSS Behavioral Surveillance Survey CI 95% 95% Confidence Interval ELISA Enzyme Linked Immuno Absorbent Assay EPI INFO A WHO statistical packages for survey study EPI Expanded Program on Immunization ESRA Economic and Social Reform Agenda HIV Human Immunodeficiency Virus IEC Information, Education and Communication MICS Multiple Indicators Cluster Survey Ml Milliliter MOHSW Ministry of Health and Social Welfare NBTS National Blood Transfusion Service NERCHA National Emergency Response Committee on HIV/AIDS PMTCT Prevention of Mother to Child Transmission PPS Probability Proportion to Size QA Quality Assurance RPR Rapid Plasma Reagin (A screening test for Syphilis) SNAP Swaziland National AIDS Program STI Sexual transmitted Infection TB Tuberculosis UNAIDS United Nations joint program on HIV/AIDS UNDP United Nations Development Program UNFPA United Nations Population Funds UNGASS United Nations General Assembly Special Session on HIV/AIDS UNICEF United Nations Children's Funds US$ United State dollars (Currency) VCT Voluntary Counseling and Testing WHO World Health Organization Page 3

6 ACKNOWLEDGEMENTS The collaboration of all regions, health facilities, laboratories, super visors, Swaziland National AIDS Program team and the core team are greatly appreciated and acknowledged for their participation and contribution to the surveillance. Special thanks go to all pregnant women who par ticipated in the study and to all partner s who supported financially and technically. These include, but not limited to; Ministry of Agriculture and Cooperatives, Public Works Depar tment, The Defense Force, Central Statistics Office, National Emergency Response Committee on HIV and AIDS, United Nations Population Fund, World Health Organization, United Nations Children's Fund, Family Health International, USAID,US Embassy (Swaziland). Page 4

7 EXECUTIVE SUMMARY Background HIV/AIDS is still one of the major challenges to the country's socio-economic development. The epidemic has continued to spread relentlessly in all the parts of the country. However, government, local, non-governmental organization and international par tners continue to commit themselves to fight the scourge. The biennial HIV sentinel surveys among pregnant women aged years attending antenatal care in various health facilities in the country have regularly been conducted in the last decade to monitor the magnitude and the progress of the epidemic. This th leaflet highlights the findings of the 8 sentinel survey carried in the year 2002 and shows trends of the HIV epidemic in Swaziland since 1992 to Objectives The objectives of the sentinel surveillance were the following! To determine the prevalence of HIV, Syphilis and Hepatitis B infections among pregnant women attending antenatal care services! To monitor trends of HIV. Syphilis and Hepatitis B among pregnant women! To determine the distribution of HIV, Syphilis and Hepatitis B in different age groups, marital status and educational status among pregnant women! To determine the prevalence of HIV, Syphilis and Hepatitis B between the 4 regions and by urban/rural strata! To collect HIV data that will enable HIV/AIDS projections in the future Methodology This survey involved HIV screening of pregnant women aged years who had visited antenatal care for the first time for the current pregnancy from selected health facilities around the country's for regions. The total collected sample size in this survey was 2,787 respondents. An anonymous and unlinked procedure was used for the HIV testing except for syphilis and hepatitis B testing. Anonymous and unlinked means that HIV results cannot be linked to individual pregnant women as their personal identifiers, such as names were not recorded Sentinel sites A total of 17 sites were selected based on the geographical distribution taking into account all the four regions in the country. Other selection criterion included; presence of health facilities offering antenatal care ser vices, existence of facilities for storing of blood specimens, ability and preparedness of antenatal care facilities to participate in the survey and the health facility having been used before in the precious sur veys. HIV testing Page 5 All samples were collected from sites and sent to the National Referral Laboratory for

8 testing. Each sample was tested for HIV using access ELISA. Any serum sample found to be reactive was re-tested on the ELYSIS ELISA. If found reactive again it was then considered to be HIV antibody positive. Strict quality assurance procedures were adhered to, to ensure reliable results. Quality Control was done internally at the National Laboratory Control Quality Control Section and externally at the National Blood Transfusion Services. RESULTS Despite the efforts made in the response to the epidemic in the country, HIV prevalence among pregnant women attending antenatal care clinics (ANC) continue to show increasing HIV infection trends. Out of the blood samples tested in 2002, the HIV prevalence among ANC pregnant women (ANC) was 38.6%. HIV infection levels have increased from 3.9% in 1992, 15.2% in 1994, 26.3% in 1996, 31.6% in1998, 34.2% in 2000 and now 38.6% this year The urgent need for expanding and scaling up the HIV/AIDS response cannot be over emphasized. For this to happen, it requires adequate mobilization and strategic allocation of resources and concerted efforts and commitment at all levels including the communities themselves to fight this epidemic. HIV infection by region 2002 While all the regions are showing relatively high HIV prevalence rates, Manzini had the highest rate of 41.2% and Hhohho had the lowest of 36.6%. However, the HIV prevalence trend over the years appear to show some degree of stabilization in the Manzini region (41.0% in 2000 Infection Among ANC Population HIV 3.9% 16.1% 26.0% 31.6% 34.2% 38.6% Syphilis Not Done 11.4% 5.5% 5.2% 6.1% 4.2% Hepatitis Not done Not done And 41.2% in 2002) and a marked increase in HIV prevalence was recorded for the Shiselweni region between the 2000 and 2002 survey (27.0% in 2000 and 37.9% in These Findings warrant the need to closely monitor the trends of the epidemic on an annual basis to better understand the dynamics of the epidemic, especially in Manzini and Shiselweni region. Also, qualitative and other studies to assess the risk factors (behavioral studies), driving forces and measurement of the impact of interventions need to be carried out to complement the ANC surveillance based HIV prevalence data. HIV infection by age group 6.7% Not done Not done 7.6% Young women below 30 years of age continue to form the majority of those infected with HIV (See Figure3). About 9 out of 10 (87%) of the infected respondents were young women under 30 years of age. HIV prevalence amongst the pregnant women aged years has also been increasing. In 2002, this young age group had an HIV infection rate of 32.5% implying that 3 out of 10 pregnant women were infected with HIV. Page 6 This high level of infection is this age group may reflect a high rate of new infections (incidence). If these trends of infection in the young people below 30 years persist, they will lead to a severe impact on the social and economic fabric of the country, since this age category represents the economical productive and reproductive population.

9 HIV prevalence by marital status HIV prevalence was equally high among those who reported being married and those reporting not married, 36.8% and 40.2% (2002) respectively. This shows that being married, is not necessarily a protective factor against HIV infection. Therefore, regardless of marital status, faithfulness in unions and protective sex should be emphasized during health education campaigns and in the promotion of safer sexual behavior. Syphilis Sexually transmitted infections (STIs) serve as an indicator of biological susceptibility to HIV infection and a proxy indicator for high risk behavior. Generally, the incidence of STIs is considered to be high in Swaziland hence likely to be accountable for the spread of the HIV virus. th Worth noting however, is that the 8 HIV sentinel survey, indicate a decrease in the prevalence of syphilis among pregnant women attending ANC (6.1% in 2000 and 4.2% in This could be attributed to improved STIs case management in the country. Such gains should not create complacency, but be a driving force to further strengthen and sustain STI management in the country. Page 7

10 CHAPTER Introduction HIV/AIDS is one of the major challenges to socio-economic development in most countries in the world today. The epidemic continues to spread relentlessly in most areas of the world. In 2001 alone, about 5 million people got infected with HIV bringing the estimated total number of people living with HIV/AIDS worldwide to 40 million. The Sub Sahara Africa with 10% of the world's population is most severely affected. About 70% (3.5 million) of all the new HIV infections in 2001 occurred in Sub Saharan Africa. By the end of 2001, UNAIDS estimated that 28.5 million people were living with HIV/AIDS in Sub Saharan Africa. At least 10% of those aged years are infected in 12 African countries. Seven of these countries are all in Southern Africa. The hope that the epidemic may have reached its natural limit has not yet come true in most of Southern Africa (UNAIDS. 2002) Most countries in Southern Africa including Swaziland have HIV rates exceeding 20% within the general reproductive age group (15-49 years) and the HIV infection trends exhibit an upward trend. According to the country's year 2000 sentinel sur veillance report, HIV prevalence rate among pregnant women attending Antenatal Care Clinics (ANC) respondents in Swaziland was 34.2% having risen steadily over the last decade amongst pregnant women from 3.9% in 1992, 15.2% in 1994, 26.3% in 1996 and 31.6% in There is however, hope that the epidemic can be brought under control. In a few countries in Africa, declining rates have been observed, for example in Zambia the propor tion of pregnant urban women aged who were HIV positive declined from 28.4% in 1993 to less than 14.8% five years later. This requires commitment and more resources to become available for prevention and care programs. Page 8 Collection and use of accurate data helps in effective prevention, control of HIV/AIDS and care of those infected and affected. The data assists to show the magnitude, distribution and demographic variations in the levels of HIV infection. Further more, knowledge of risk factors can assist in designing cost effective interventions, monitoring and evaluating effectiveness and impact of the interventions. HIV sentinel surveillance is one of the systems that many countries worldwide are utilizing to map the epidemic and monitor HIV infection levels and trends. Additionally, countries are using sentinel surveillance data as an advocacy tool to createawareness about AIDS and also to some extent to mobilize resources. Sentinel data has also been used, to some degree in some countries to monitor and evaluate pre vention and care programs Sentinel Surveillance is the serial collection of HIV prevalence data over time and place in

11 selected groups of population in order to monitor trends in HIV infection. In Africa, 70% of the countries are implementing HIV sentinel surveillance using pregnant women attending antenatal clinics (ANC attendees) as the main sentinel population. Population based HIV sero-surveys conducted in the African region have shown that HIV prevalence among pregnant women attending ANC clinics closely reflects HIV prevalence in the general reproductive population. Swaziland, like many other countries in the region, has been utilizing ANC attendees as a sentinel group since Pregnant women are used as proxy for monitoring HIV prevalence among the reproductive age group (15 49 years) because they are sexually active and constitute a definable, accessible and stable population. Swaziland has also been monitoring HIV prevalence among patients with Sexually Transmitted Infections (STIs) and TB patients. In the 2002 HIV sentinel surveillance sur vey; only pregnant women attending antenatal clinics were used as a sentinel population group. Since 1996, sentinel surveys in Swaziland have been conducted ever y two years among ANC attendees, STI patients and newly diagnosed TB patients. The HIV prevalence surveys among the STI and TB patients were conducted simultaneously with the surveys among the ANC attendees at the same health facilities. From 2002, onwards the Ministry of Health & Social Welfare is planning to be conducting sentinel surveys among ANC attendees annually and less frequently among the STI and TB patients. In order to obtain a better understanding of the dynamics of the epidemic in the country, Swaziland has conducted Behavioural Surveillance Surveys (BSS) among the Youth, adults, commercial sex workers, long distance truck drivers and migrant workers. At the time of writing this report, the results of this behavioural surveillance survey were not yet officially available hence they will not be inferred to in this report. This repor t presents the findings, conclusions and recommendations of the 8th HIV Sentinel Surveillance Sur vey including syphilis and hepatitis B conducted in 2002 at selected sites across the four regions of Swaziland. Page 9 Survaillance data processing facility at the Goverment hospital

12 CHAPTER Country profile The Kingdom of Swaziland is located in Southern Africa and covers a surface area of 17,000 square kilometers. Swaziland shares borders with Mozambique in the east and the Republic of South Africa in the South, North and West. The country is divided into four regions namely, Manzini, Hhohho, Lubombo and Shiselweni. The population was 929,718 in 1997 with about 46% of the population aged years. According to the 1997 census, of the population were males and were females. Notably, the population of the Manzini region is slightly higher than the other regions (30.2%) census. In the Manzini region, Manzini town is the industrial town and hub of the country. The 1997 census also showed that a total of 66% of de facto household heads were female and 5.4% were aged below 20 years. Also according to the 1997 census, the majority (77%) of the Swazi population was living in rural areas with only 23% of the population living in urban or peri-urban areas. Like in many African countries, most people in Swaziland live off subsistence farming. Swaziland like most countries in Southern Africa was hit by drought in 2002, which lead to thousands of the population exposed to starvation. Two thirds of the Swazi population live below the poverty line defined as E70.00 (about US$7.00) per month, in spite of a high per capita income of US$1 350 (2000). Life expectancy in Swaziland has been repor ted to be declining from 65 years for females and 58 years for females in It is projected that if current trends in HIV infection persist, life expectancy in Swaziland will fall below 30 year s by year The Swazi nation has a strong culture centered around the monarchy. The country is homogenous in terms of culture and language. Both siswati and English are official languages in Swaziland. The country is divided into four regions and further divided into 55 political constituencies known as Tinkhundla, each Inkhundla is made up of several chiefdoms and is headed by an elected individual known as Indvuna. The chiefdoms are made up of clusters of homesteads forming communities. These are headed by the chiefs who are appointed by His Majesty the King, who delegate authority to them based on heritage. 2.1 Health Care System Page 10 Health care service in Swaziland is not only offered through the modern /western method, but traditional medicine is practiced through traditional healers/herbalists, etc. The western/modern health care system in Swaziland is decentralized into the four administrative regions of the country. Each region coordinates its activities, however all the regional activities are coordinated at the central level. The country has both private and public health facilities distributed around the country. The country's health care delivery system is divided into three main levels namely the clinic which is the first level of contact and a primary health care unit, the health center/public Health Units which is the second level of contact and the hospital which is

13 the last level. A bout 80% of the total population resides within 8 km radius of a health facility. All these facilities offer various services which include antenatal care. This accounts to the fact that more than 80% of pregnant women are reported to make contact with the ANC ser vices at least once during pregnancy (Safe motherhood repor t 1995/96). Community participation and involvement is ensured by the recruitment and training of rural health motivators (RHM's) whose duties include giving health talks, condom distribution, advising communities on issues such as environmental sanitation, breastfeeding and general prevention of diseases. Regarding Safe motherhood, the Ministry of Health and Social Welfare in collaboration with communities identified and trained traditional birth attendants on safe emergency delivery methods to reduce neonatal and mater nal mortality rates. Investments in health have declined from about US$70 per capita in the late 1980s and early 1990s to about US$ 24. The kingdom of Swaziland on average has been spending 9% of its budget on health for the last ten years. However, a there has been a decrease in the health budget over the years. With increasing morbidity due to AIDS related conditions, the health expenditures are likely to increase. About 75.6% of the health budget is allocated to curative services. Only 14.18% is allocated to preventive and health promotion services. Yet, preventable environmental factors are the major determinants of morbidity and mortality in the country (the National Strategic Framework on HIV/AIDS ). 2.2 National Response to HIV/AIDS HIV/AIDS is a major socio-economic developmental and a health problem in Swaziland. Ever since the first HIV case was reported in 1986, the epidemic has continued to increase. In 1987 the first AIDS case was reported in the countr y. The government of Swaziland in collaboration with World health Organization (WHO) established the Swaziland National AIDS/STIs Program (SNAP). The program was established under the Ministry of Health and Social Welfare (MOH&SW). The major goal of this program was to reduce the spread of the Human Immunodeficiency Virus (HIV). The program was to achieve this through information, education and communication (IEC) campaigns; informing the public on the modes of HIV transmission and ways of avoiding HIV infection. Initial efforts led to the implementation of an emergency plan of action. Advisory boards like the national IEC committee were formed and mandatory screening of all blood for transfusion was initiated. The SNAP was also mandated with the responsibility of coordinating all HIV/ AIDS related activities in the countr y. As it became increasingly clear that AIDS was more than just a health problem, many stake holders both in government, communities and private sectors initiated programs aimed at curtailing the spread of HIV in Swaziland. In 1999, the Government of Swaziland created and launched the Cabinet Committee on HIV/AIDS and the Crisis Management and Technical Committee. At the regional level, multi-sectoral HIV/AIDS councils were established. An HIV/AIDS policy was developed, and approved by cabinet in The HIV/AIDS/STIs policy mainly focuses on the three components which are Prevention, Care and Support and Impact Mitigation. The Economic and Social Reform agenda (ESRA) also recognizes the threat posed by the epidemic. In February 1999, His Majesty King Mswati III declared HIV/AIDS a national disaster. Page 11 National Emergency Response Committee on HIV/AIDS (NERCHA) is now mandated to coordinate and mobilize resources for an expanded, scale up and coordinated response in the country. In order for NERCHA and all the various stakeholders to achieve their goal of reducing the spread of HIV/AIDS in Swaziland, timely and accurate data on HIV/AIDS and the risk factors are an essential and crucial component for designing innovative HIV prevention and care approaches.

14 Life expectancy 60 years 1997 Population census Infant mortality rate 87.7 per 1000 MICS 2000 Under five mortality rate 122 per 1000 MICS 2000 Maternal mortality rate 229 per 100, Maternal mortality review Total fertility rate Population census Adult literacy 79.2 percent 1997Ppopulation census Crude death rate Population census Use of safe drinking water 51 percent MICS 2000 Use of sanitary means of 72 percent MICS 2000 excreta disposal Antenatal care 79 percent Contraceptive prevalence 27.9 percent MICS 2000 Exclusive breastfeeding 31.2 percent MICS 2000 (Breastfeeding up to 4 months Women s knowledge on 49.5 percent MICS 2000 prevention of HIV/AIDS Knowledge of misconceptions 41 percent MICS 2000 Knowledge of mother to child 47 percent MICS 2000 transmission Attitude to people with HIV/AIDS 77.4 percent MICS 2000 Women who know where to be 59.7 percent MICS 2000 tested for HIV Women who have tested for HIV 17.3 percent MICS 2000 Table 1: Key Indicators N.B. It should be noted that some of the indicators do not factor in the impact of the HIV/AIDS epidemic Page 12 Taking blood samples at Mbabane PHU

15 CHAPTER 3 SURVEY OBJECTIVES th The objectives of the 8 HIV Sentinel Surveillance Sur vey, 2002 were as follows-: 3.1 General Objective To obtain data that will show the trends of the epidemic in Swaziland, and contribute in advocacy and planning strategies for prevention and Control of HIV/AIDS and Sexually Transmitted Infections (STIs). 3.2 Specific Objectives To determine the prevalence of HIV, hepatitis and syphilis infection among pregnant women attending Antenatal Clinics (ANC) To monitor trends of HIV infection and Syphilis infection among pregnant women attending antenatal clinics To determine demographic variations in prevalence of HIV infection among pregnant women attending antenatal clinics in the country To provide information on the prevalence of HIV infection, Syphilis and Hepatitis for purposes of guiding planning, designing prevention policy formulation, and Care interventions. Page 13

16 CHAPTER Sampling procedures Sentinel population The sentinel population used during the 2002 HIV sentinel surveillance survey was pregnant women attending antenatal clinics (ANC attendees) in selected health facilities in the four regions in the country. All pregnant women aged15-49 years attending antenatal care for the first time, for the current pregnancy were recruited into the sentinel sample using anonymous and unlinked procedures, except for syphilis and hepatitis B. Pregnant women were chosen because they are easily identifiable and accessible at health facilities. They also form a stable population and represent the reproductive population group. Pregnant women serve as an important population group to monitor both heterosexual and peri-natal transmission of HIV. The routine drawing of blood haemogram and or syphilis screening make it possible for anonymous and unlinked HIV testing on residual blood Sentinel Sites The selection of sites was based on the geographical distribution taking into account all the four regions in the country, presence of health facilities with antenatal care services, existence of facilities for storing of blood specimens, ability and willingness of antenatal care providers to cooperate and participate in the survey and the health facility having been used before in the previous surveys. Health facilities meeting these criteria were further stratified into urban and rural. For each of the stratum and site, the study population was determined using Probability Proportional to Size (PPS) technique. Four sites; two urban and two rural were selected in each of the regions with the exception of Lubombo where three rural sites and two urban sites were used Sample Size Page 14 Sample size for the survey was calculated based on the propor tion of ANC attendees expected to be HIV positive with the assumption that the HIV prevalence among the ANC attendees would be the same as the prevalence rate obtained in Therefore, an HIV prevalence rate of 34.2% (2000 HIV sentinel surveillance figure for Swaziland) was used. The EPI INFO statistical calculator for determining sample sizes for dichotomous descriptive studies such as this one was used and adopted at 95% confidence interval (CI). This calculation was based on this 2 formula N=4Z P (1-P)/W, where N stands for sample size, P for propor tion positive, W for desired total width of the confidence interval and Z is 1.96 when the 95% confidence interval is adopted. The calculated required sample size for this sur vey was 2,157.

17 4.1.4 Sampling procedure and Sampling Period Consecutive sampling of all the pregnant women aged years attending antenatal care for the first time for the current pregnancy was done until the required sample size was obtained. Sample collection from all the sites started on the 17/06/02 and ended on the 02/8/02 in all the sites apart from three where it ended on the 16/8/02. On average the sampling lasted for 6 weeks at the 14 sites and 8 weeks at the three to allow for the required sample size to be achieved. 4.2 Data collection instrument A questionnaire was used to collect information on individual demographic characteristics such as age in years, level of education, nationality and marital status, region, residence (rural or urban) strata. No names of individuals were taken and recorded. A unique field number was allocated to each of the participating pregnant women and it is this number that was recorded on the questionnaire and also used for labeling the blood samples. (See Annex) 4.3 Training of research assistants, laborator y technicians and supervisor s A three day training program for supervisors, research assistants and laboratory technicians was done centrally. The objective of the training was to standardize the survey data collection and orient all involved in the survey accordingly. The training covered criteria for selection of the sites, recruitment of the pregnant women, questionnaire administration, blood sample collection, labeling, coding, serum separation, storage and transportation, syphilis, hepatitis and HIV testing, confidentiality and ethical issues, supervision and quality assurance procedures. A separate training program was organized for Laboratory personnel in sample reception and recording, processing, quality assurance, result transmission and on ethical issues. 4.4 Survey Preparation A meeting of key stakeholders was held before the implementation of the survey to discuss and th agree on the contents of the sentinel surveillance protocol to be used in the 8 HIV sentinel surveillance sur vey. All the stakeholders were informed of the objectives of the survey. The purpose of the meeting like this is likely to increase ownership of the data and its utilization. The outcome of the meeting including ethical issues within the protocol was cleared by the relevant authorities within the Ministry of Health & Social Welfare. The surveillance sites were visited by the supervisors to ascertain their preparedness for the surveillance survey. 4.5 Field procedures: data collection and specimen collection Page 15 Individual verbal consent was obtained for answering the questions on the questionnaire. Routinely in the ANC clinics syphilis screening is done. Hence, syphilis screening was used as an entry point for HIV testing using anonymous unlinked procedures; a practice that is utilized by most countries in the region implementing HIV sentinel surveillance. Two blood samples were taken by vein puncture; seven (7) ml was collected into a serum separator tube (plain tube with gel) and allowed to clot and another 5 ml was put into an EDTA vacutainer tube. Both samples were labeled with the field number of the individual pregnant woman and placed in a rack in ascending numerical order at room temperature for not more than eight hours from time of collection. At the close of each day, the questionnaires were checked alongside the blood samples by the supervisors for mistakes, completeness and labeling in the case of the blood specimens.

18 The samples, together with the questionnaires were shipped in a cooler box to the National Referral Laboratory. Data and specimen collection took a total of 9 weeks considering the extra 2 weeks for the 3 sites. 4.6 Laboratory procedures HIV testing All samples were recorded in a laboratory logbook according to their sur veillance sites. For HIV testing, each sample was tested using Access ELISA method from Beckman Coulter. Any serum sample that was found reactive was tested again on the Elysis ELISA method. If it was still found to be reactive it was repor ted as HIV antibody positive. Samples that were not reactive on the first ELISA were considered HIV antibody negative. Discordant samples were re-run on a rapid Western Blot method manufactured by Organics which was used as a tiebreaker. A discordant result that was still indeterminate on Western blot was discarded. Two samples out of the 2789 tested were found to be indeterminate by the Western Blot method and therefore discarded. It is important to note that WHO recommends use of a single ELISA test for surveillance purposes in countries with high HIV prevalence such as Swaziland. However, to increase confidence in the results two tests were performed in series Hepatitis B surface Antigen testing All samples were tested for hepatitis B surface Antigen using Elysis ELISA method from Human. Any sample that was found reactive was repor ted as positive. No further tests were performed Syphilis testing All serum samples were tested using Rapid Plasma Reagin (RPR) test containing carbon antigen. Samples that were found reactive had their titres determined. No further tests were performed Recording and transmission of results! All the HIV, hepatitis and RPR results were entered in the laboratory log book, which is kept in the laboratory.! All the HIV, hepatitis and RPR results were reported on the questionnaire and forwarded to the coordinating office (SNAP) through the senior laborator y technologist.! Hepatitis and RPR results were entered into another form and forwarded directly to the sentinel site for routine antenatal care management. 4.7 Laboratory Quality Assurance The following measures were applied regarding quality assurance for HIV testing.! An evaluation and comparative study of the performance of the two ELISA methods th including ELISA methods used in the 7 sentinel surveillance was carried out. The evaluation revealed a 100% concordance. Page 16! All equipment was serviced prior to the sentinel surveillance sur vey and there after routine

19 maintenance procedures were followed during the entire period of the survey.! All the runs included manufactures internal control and Levy-Jennings graphs were drawn where applicable.! All new batches of HIV kits were validated using a total quality system of an anti HIV 1 and 2 qualification panel consisting of 6 members. The qualification panel is manufactured by BBI Diagnostics.! No kits that had exceeded the expiry dates were used.! 10% of randomly selected surveillance samples were re-run at the National Blood Transfusion Service and were found to be 100% concordant! The laboratory supervisor verified all the results before being recorded on the data form. 0! All samples will be stored at 40 C for at least one year for any follow up testing, external QA or audit.! The laboratory logbook and QA documentation will also be kept in the laboratory for at least 5 years in case an audit is to be done. 4.8 Supervision of the survey th The 8 sentinel surveillance was conducted by the national sur veillance committee consisting of experts in the various priority areas. The committee was headed by the Program Manager of the National AIDS Program. The program manager visited each sur veillance site once a week. Each region had one supervisor whose duties were to consistently monitor the collection, transportation and delivery of blood samples during the entire survey. Each supervisor visited one site per day. The Regional Supervisor s reported to the National Program Manager any logistical and technical issues. All surveillance activities in the laboratory were supervised by the laboratory super visor of the National Referral Laboratory. Logistical aspects were handled by the senior technologist at the Central Public Health Laboratory. External quality assurance was done at the National Blood Transfusion Service (NBTS) 4.9 Data entry and analysis The data collection forms were first checked for completeness, obvious mistakes and inconsistencies in the field. EPI INFO statistical software was used for data entry, validation and analysis. A check program was created to ensure that only legal entries were entered. The analysis was mainly descriptive and focused on determining the prevalence rate of HIV, syphilis and hepatitis B by the relevant variables such as region, age, marital status and educational level. National (overall) prevalence rates were also determined Limitations of the survey Page 17 The use of pregnant mothers attending antenatal clinics raises issues on the representativeness of this sentinel population to the general population or even women in general. Sentinel surveillance in ANC clinics has an inherent selection bias against women using Modern contraceptives. Women who have adopted safer sexual behaviors such as use of consistent condom use are unlikely to become pregnant and therefore not attend antenatal

20 Page 18 care. Women with infertility are not likely to be captured in the ANC clinics. Infertility caused by STIs would tend to result in an underestimation of HIV prevalence rates especially in the older age groups where infer tility is most common. However, infertility due to STIs and HIV are unlikely to affect the HIV prevalence rates in the young age groups years. Fortunately enough the ANC based data has been found to closely reflect the HIV prevalence in the reproductive age group.

21 CHAPTER 5 RESULTS OF THE SENTINEL SERO-SURVEILLANCE SURVEY Background Characteristics of the respondents A total of 2,789 pregnant women attending antenatal care (ANC attendees) at selected health facilities in four regions in the country were recruited into the sentinel sample from the17th June th 2002 to 16 August The response rate was 100%; there were no refusals. During the HIV testing of samples, two samples were found indeterminate and were discarded in the data analysis Place of residence The sentinel sites were selected from both urban and rural areas in all four regions. There were 2,787 pregnant women that were recr uited, and out of those 1,581 (56.7%) and 1,206 (43.3%) were residing in the urban and rural areas respectively. These proportions when compared with those the previous years were found to be similar, indicating no significant differences. The map below shows the location of the sentinel sites that were used in the eighth HIV sentinel surveillance sur vey (2002). Page 19 Pregrant woman attending antenatal care

22 SENTINEL SITES TH SURVEILLANCE H2 HHOHHO HI H3 L2 L1 H4 M3 M2 MANZINI M4 M1 LUBOMBO L4 L3 S1 SHISELWENI S2 S3 S4 L5 N Facility Figure1: Geographical location of HIV sentinel sites in 2002 Legend: Hhohho Region H1=Mkhuzweni Health Center H2=Piggs Peak PHU H3=Dvokolwako Health Center H4=Mbabane PHU Lubombo Region L1=Lomahasha Clinic L2=Vuvulane Clinic L3=Siteki PHU L4=Sithobela Health Center L5=Ndzevane Clinic Manzini Region M1=Family Health Association M2=King Sobhuza 11 Health Center M3=Luyengo Clinic M4=Mankayane PHU Shiselweni S1=Hlatikulu PHU S2=Dwaleni Clinic S3=Nhlangano Health Center S4=Matsanjeni Health Center Page 20

23 5.1.2 Age distribution Age is an important background characteristic of respondents because it is central to most of the analysis and is crucial in the design of HIV/AIDS strategy and interventions. Two thousand seven hundred eighty four (99.9%) respondents had their ages recorded; age was missing only for three pregnant women. Table 1: gives an age distribution of the respondents in As expected, the percentages shown in the table decrease with age from 15 to 49 years. About 65.8% of the respondents were young women aged years. The same pattern in age distribution is observed in all the regions, except the Manzini region where prevalence is higher among the years age group. The effect of ageing out of the fer tility period as one grows older and probably the effect of mortality is probably reflected in the age distribution of the respondents in the older age groups in the table below. Table 3: Distribution of ANC respondents by age group and region 2002 Age in National Hhohho Lubombo Manzini Shiselweni years No. % No. % No. % No. % No. % Unknow n Total 2, * * * It may not add up to 100% due to rounding. Table 4 shows age distribution of the ANC respondents from 1994 to 2002 enrolled in the sentinel surveys. This indicates similar patterns over the years. There is an increase in the proportion of young pregnant women aged years. Table 4 : Age distribution of ANC Respondents Age in years No. % No. % No. % No. % No. % Unknown Total , * Educational status The ANC respondents were asked whether they had been to school or not. In the survey, five categories were envisaged: no formal education, primary, secondary, tertiary and vocational. The responses to this question are summarized in table 3. The majority of the respondents (88.9%) reported to have received formal education and only 11.1% had not. The educational

24 level categories below indicate that most ANC respondents had attained secondary or high school education (45.6%), followed by those who had attained primary level of education (29.5%), then those with tertiar y education (university and college) 11.6% and 2.2% had received vocational training. Vocational training was defined as having not acquired formal education, but formal attainment of specific skills. Table 5: Distribution of ANC respondents by educational level, 2002 Level No. Tested % No formal education Primary Secondary Tertiary Vocational Total Marital status In 2002 sentinel survey unlike in the previous years, only two categories were used; married and not married. Being married encompassed marriage by civil rites and customary law. Of the 2,787 pregnant women recruited into the 2002 HIV sentinel survey, 1,328 (47.6%) were married and 1,459 (52.4%) were not. Table 4 shows the distribution of the ANC respondents by age and marital status. The table indicates that the proportion of those who repor ted being married increases with age. It's wor th noting that a significant proportion (32.6%) of respondents in the age group repor ted being married. Table 6: Distribution of ANC respondents by marital status and age2002 Marital status Age group in years Married 281 (32.6) 385 (39.5) 275 (62.2) 245 (74.0) 110 (77.5) 31(93.9) Not Married 580 (67.4) 590 (60.5) 167 (37.8) 86 (26.0) 32 (22.5) 2 (6.1) No. tested HIV PREVALENCE AND TRENDS This section describes the current HIV sero-prevalence as well as the demographic variations in HIV infection rates among pregnant women attending antenatal care clinics (ANC respondents) in In order to assess the trends in HIV infection in the country and by region, the section

25 Table 7: HIV infection trends among ANC respondents in Swaziland Year HIV prevalence (%) ( ) ( ) ( ) ( ) ) ) (CI 95%) No. Tested 726 2,343 2,468 1,659 2,316 2,787 Figure 2: HIV Prevalance among ANC Respondents Figure 2:HIV Prevalence among ANC Respondents % "1992 "1994 "1996 "1998 "2000 "2002 Year Regional HIV Prevalence Table 6 indicates HIV prevalence among ANC respondents by region. Whilst all the regions are showing high HIV prevalence rates, Manzini had the highest rate of 41.2% and Hhohho had the lowest rate with 36.6%. The differences in the prevalence rates wer e not statistically significant. Table 8: HIV Prevalence Among ANC respondence by region in 2002 Region No. Tested HIV Prevalence (%) (95% CI) Hhohho ( ) Lubombo ( ) Manzini ( ) Shiselweni ( ) Total 2, ( )

26 Figure 3: HIV prevalence rates among ANC respondents by region in 2002 HIV Prevalence by Region % Hhohho Lubombo Manzini Shiselw eni Regions Since 1994 the HIV prevalence has been increasing in all the regions. From 1996 the Manzini region had the highest rates compared to the other regions; however, the 2002 survey seems to indicate some degree of stabilization in Manzini. On the other hand, in the Shiselweni region, there was a marked increase in HIV prevalence rate from 27 percent in 2000 to 37.9 percent in 2002 (29% increase). Table 9: HIV infection trends among ANC respondents by region, Region HIV Prevalence (%) Hhohho Lubombo Manzini Shiselweni PICTURE Page 24

27 % Figure 4: HIV Prevelance trends by region Years Hhohho Lubombo Manzini Shiselw HIV Prevalence by Residence The HIV prevalence rates were similar in both rural and urban areas in 2002 though the urban area had slightly higher HIV prevalence even when compared to the previous year as indicated in table 8. It is worth noting that when HIV prevalence by residence is fur ther stratified by age group, there were marked differences in HIV prevalence patterns between urban and rural. The age specific HIV prevalence rates in the urban areas were higher than those in the rural area. Comparing the HIV prevalence in the two year period (2000 and 2002), there has been a sharp increase in the age group 15 to 19 years in the urban areas whilst in the rural it appears stable. The reverse pattern is seen in the age group 20 to 24 years. Figure 5: HIV Prevelance by Residence HIV Prevalence by Urban/Rural residence % Page 25 0 Urban Residence Rural

28 Table 10: HIV prevalence among ANC respondents by age and residence ( ) HIV Prevalence (%) Age-Group Urban 2000 Urban 2002 Rural 2000 Rural ** Total ** Sample size too small (8 respondents) thus has to be interpreted with caution HIV Prevalence by age The age specific HIV prevalence rates among ANC respondents were analyzed and are indicated in table 9. The 25 to 29 age group had the highest prevalence followed by the 20 to 24 year age group. The HIV prevalence amongst the adolescents (15-19) was 32.5%. This is rather a high rate for this age group as the infections in this age group reflect new HIV infections than old infections. The age group 15 to 24 years is used as an impact assessment indicator for establishing infection rate amongst the young population and monitoring achievements towards United Nations General Assembly Special Session on HIV/AIDS (UNGASS) targets. The HIV prevalence amongst this group was 41.6% (95% CI: ). Worth noting is that 67% of the HIV infected pregnant women were less than 25 years. About 87% of the infected pregnant women were below 30 years of age. Table 11: HIV infection rates Among ANC respondents by age group 2002 Age group in years No. Tested HIV prevalence (%) Unspecified ( ) 45.4 ( ) 47.7 ( ) 29.6 ( ) 23.9 ( ) 24.2 ( ) 0.0 Total ( ) The graph below illustrates HIV prevalence rate by single year. This graph shows a marked increase in HIV prevalence from the age 16 year to age 25 and a decline from the age 26 and above. This apparent decline is most likely due to aging out of fertility period and ear ly mortality, hence the chance of getting pregnant reduced. There is need to further investigate and discuss the sudden increase in HIV prevalence rate between age 16 and 17 and then to 22 years. Page 26

29 Figure 6: HIV prevalance by single age from 15 t0 30 years amon ANC respondents 2002 HIV Prevalence by Single age % Age In all the age groups there is generally an increase in HIV prevalence amongst all the groups over the years. Since 1994 to 2000 the age group 20 to 24 years has been having the highest HIV prevalence rates. However in 2002, age group 25 to 29 years had the highest HIV prevalence followed by the age group 20 to 24 years. Table 12: HIV prevalence among ANC respondents by age group Age group in years HIV Prevalence (%) Total Page 27

30 5.2.5 HIV by educational status 2002 Figure 7: HIV Prevalence Trends by Year % Age group The level of education even though not statistically significant, seems to have an effect on the HIV infection as illustrated in figure 6. The respondents who repor ted to have attained primary level of education had the highest HIV prevalence rate (40.1%, 95%CI: ) and the lowest HIV prevalence rate was among those who had attained vocational training (35.5%, 95% CI: ). Those who had attained secondary/high had an HIV prevalence of 38.3% (95% CI: ), among those who had attained tertiary education the rate was 37.5% (95% CI: ) and those who had no education the rate was 37.1% (95% CI: PICTURE Page 28

31 Figure 8: HIV prevalance by of education status, 2002s HIV prevalence by level of education % No Education Primary Secondary /High Tertiary Vocational Level of education HIV Prevalence by marital status Respondents were asked on their marital status. Out of 1,328 who reported being mar ried, 36.8% tested positive and those that were not married, 40.2% tested positive. The differences were not statistically significant (Chi-square 3.28 p-value 0.07). The rates as shown in table 11 were high over the age groups in both respondents who repor ted being married and those reporting not married. Comparing the 15 to 19 year age group there were marked differences in the prevalence rates with those reporting the married having a higher rate (38.8%) than those who repor ted not being married (29.5%). Among the 20 to 34 year age group those who reported not being married had a significantly higher rate than those who reported being married. Table 13: HIV Prevalence by marital status and age Age group HIV Prevalence Married Not married NO. TESTE D % NO. TESTE D % ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) 2 * Total ( ) ( ) Page 29 * Sample size too small to make meaningful inference.

32 5.3 SYPHILIS PREVALENCE Syphilis Prevalence by national, region and age All the respondents (2,787) were screened for syphilis using RPR in 2002, which is done on routine basis amongst the ANC attendees and of these 4.2% (95% CI: ) were positive. When analyzed by region, the syphilis prevalence was evenly distributed across the four regions, in Hhohho the prevalence was 4.7%, Lubombo 4.5%, Manzini 4.3% and Shiselweni had the lowest rate of 3.2%. In all the age groups the prevalence of syphilis was relatively low, but the age group years had the highest rate as shown in table 12 and in figure 7. Table 14: Syphilis Prevalence by age Age group Syphilis prevalence No. Tested Percent Total Figure 9: Syphi;is Prevalence (%) by Age, 2002 Syphilis Prevalence (%) by Age, % Age group 0 Page 30

33 5.3.2 Syphilis prevalence trends Syphilis prevalence rates compared over the years ( ) among ANC respondents indicate a declining trend as shown in figure 9. Over the years a declining trend is observed from 11.4% in 1994, 5.5% in 1996, 5.2% in 1998, 6.1% in 2000 and 4.2% in Figure 10: Prevalence Trends Syphilis Prevalence (%) trend Among ANC Respondents, % Years Syphilis Prevalence by HIV Sero status Respondents were screened for syphilis and HIV. Out of the 2,670 who tested negative on RPR, 37.9% were HIV positive whilst 117 who tested positive on RPR, 53.0% tested HIV positive. There is an indication of a strong association between positive syphilis serology and being HIV positive (Risk Ratio: 1.40, p-value 0.001). This implies that there is an increased risk of being HIV positive if one has syphilis. Table 15: HIV prevalence by RPR status RPR test No. Tested HIV prevalence (%) Negative (non reactive) Positive (reactive HEPATITIS PREVALENCE Hepatitis B Prevalence by national, region and age Page 31 Two thousand and seven hundred and eighty seven (2 787)ANC respondents were screened for hepatitis B surface antigen. The national prevalence was found to be 7.6% (95% CI: ). When analyzed by region, the hepatitis prevalence was evenly distributed across the four regions ranging from 7.0% to 7.9%. The hepatitis B prevalence was lower in the age group 25

34 to 29 years, whilst the others had almost similar rates. It is worth noting though that the young adults (15-24 years) had hepatitis B prevalence ranging from 8.1% to 8.4%. Table 16: Hepatitis Prevalence by age Age group Hepatitis prevalence No. Tested Percent Total Hepatitis B Prevalence by HIV Sero status Respondents were screened for hepatitis B and HIV. Out of the 2,572 who tested negative on hepatitis B test, 38.4% were HIV positive whilst 212 who tested positive on hepatitis B, 40.6% tested HIV positive. These results show no association between positive hepatitis B and HIV seropositive (Risk Ratio: 1.06, p-value 0.53). Table 17: HIV prevalence by Hepatitis B status Hepatitis B test No. Tested HIV prevalence (%) Negative (non reactive) Positive (reactive Page 32

35 CHAPTER 6 CONCLUSIONS AND RECOMMENDATIONS His section highlights major findings of the eighth sentinel surveillance sur vey (2002) from which conclusions and recommendation are drawn. The chapter is organized in such a way that findings on a particular issue are presented and are immediately followed by the relevant recommendations in bold. The recommendations are in bold. The HIV prevalence trends in the country are still increasing. The HIV prevalence among pregnant was 3.9% in 1992, 16.1% in 1994, 26% in 1996, 31.6% in 1998, 34.2% in 2000 and then 38.6% in The HIV prevalence trends in the four regions are increasing with an exception of the Manzini region, which has remained at 41%. A marked increase in HIV prevalence is observed in Shiselweni region from 27% in 2000 to 37.9% in Despite the efforts made in response to the epidemic, there is still a need for expanding and scaling up the HIV/AIDS response through coordinated and targeted interventions. Therefore increased resource mobilization should be made by the government and other par tners to fight HIV/AIDS epidemic focusing prevention, care and suppor t, as well as impact mitigation. It is recommended that the findings of the high sero HIV prevalence rates be used in the design of interventions; such as health education campaigns, condom promotion especially dual protection, making available and accessible PMTCT and VCT services, and protection of child rights and vulnerable populations. There is a need to closely monitor the trends of the epidemic on an annual basis to understand the dynamics of the epidemic especially in Manzini and Shiselweni regions, and the sentinel surveys should be complemented with special studies to assess the risk factor s and impact of interventions. (Special studies) Findings from the sentinel surveys and related HIV/AIDS research should be used in generating future research questions and redesigning and planning of relevant or associated program areas such as communicable and Non-communicable diseases. Page 33 About 87 percent of the infected ANC respondents were young women under 30 years of age and 67 percent of these infected women were below 25 years of age. Adolescents (15-19 years) had HIV prevalence of 32.5 percent, indicating that one in three of surveyed adolescents are infected.it is worth noting that among the age group, 32.6 percent reported being married and out of these 38.8 percent tested HIV positive.

36 There is an urgent need to re enforce the existing intervention, as well as putting in place innovative approaches and special programs for young people to cope with the big magnitude of the HIV/AIDS epidemic in the country, such as strengthening and expanding Youth friendly services, including making available, accessible and affordable VCT services to the youth and the design of appropriate IEC messages for the youth. Both in and out of school adolescents (10-19 years) should be targeted with specific strategies, which should include sex education and life skills. Respondents who reported to have attained primary level education had the highest HIV prevalence (40.1%) compared to those who had attained higher education level There is need to integrate family life education with emphasis on sexuality, HIV/AIDS and reproductive health issues from primar y and at all levels in the school curriculum. HIV prevalence was equally high among those who reported being married and those reporting not married (36.8% Vs 40.2%). From this survey result, being married is not a protective factor against HIV infection. It is recommended that regardless of marital status, faithfulness in unions and protective sex should be emphasized during health education campaigns and in the strategy on promotion of safer sexual behavior. There were no significant differences in HIV prevalence rates between urban and rural areas. However, marked differences were observed in the 15 to 19 years age group stratified by rural/urban residence, urban being 34.9% and rural 28.1%. These findings indicate the need for using different but complimentary strategies and interventions in the urban and r ural areas, as well as for different population groups. HIV prevalence is increasing r apidly in the country, especially among the young people This creates an urgent need for understanding the driving forces of the epidemic in these young age groups which requires conducting periodic qualitative and quantitative special studies in both urban and rural areas. These data should be used in policy, design and review, as well as evaluation of interventions for the youth. Although there is a strong association between syphilis and HIV infection, the sur vey results show relatively low rates of syphilis (4.2%). Over the years a declining trend is obser ved from 11.4% in 1994, 5.5% in 1996, 6.1% in 2000 and 4.2% in This decline is most likely to be attributable to the improved STI case management in the country with the adoption of the syndromic management and training of service provider s and the availability of STI drugs. The STI case management should be strengthened and sustained. Training of service providers and provision of youth friendly services should be strengthened. The prevalence of hepatitis B has moderately increased from 6.7% in 1996 to 7.6% in The survey results though indicate that it's evenly distributed across the regions. Among the surveyed ANC attendees aged 15 to 24 years, the prevalence rates ranged from 8.1% to 8.4%. Page 34 There is a need to strengthen and coordinate and liase with the EPI and HIV/AIDS programs (EPI)..MAVIS)

37 REFERENCES Central Statistical office: Swaziland Population and Housing Census, 1994 Report on Mater nal mortality review in the Kingdom of Swaziland, December 2001 Multiple indicator cluster survey full report, 2000 The Social Aspects of HIV/AIDS Research, September 2002 Report on the global HIV/AIDS epidemic, UNAIDS report, 2002 Swaziland HIV Sentinel Surveillance report 1992 Swaziland HIV Sentinel Surveillance report 1994 Swaziland HIV Sentinel Surveillance report 1996 Swaziland HIV Sentinel Surveillance report 1998 Swaziland HIV Sentinel Surveillance report 2000 Shiselweni baseline study, 2001 report Launch of the Alliance of Mayors and Municipal Leaders on HIV/AIDS in Africa Swaziland Chapter, January 2000 Stanecki 2001 Swaziland HIV/AIDS Projections, unpublished. Swaziland Government health Statistical Repor t, Swaziland Population and Housing Census (Vol. 4 Analytical Report) Swaziland National Strategic Plan for HIV/AIDS ( ) Page 35

38 SENTINEL SURVELLANCE REGISTRATION FORM A.COLLECTION OF BLOOD SAMPLES DATE OF VISIT REGION # 1=HHOHHO 2=LUBOMBO 3=MANZINI 4=SHISELWENI 2. URBAN/RURAL # URBAN=1 RURAL=2 3.HEALTH FACILITY CODE PPU (EG Piggs peak) SAMPLE ID NUMBER AGE(IN YEARS) ## 6.LEVEL OF EDUCATION # (1=PRIMARY 2= SECONDARY 3=TERTIARY 4=VOCATIONAL 5=NONE)---!MARITAL STATUS # (1= YES 2=NO) 9. NATIONALITY # (1=SWAZI 2=NON SWAZI) NAME OF MCH SIGNAUTRE (MCH) DATE LABORATORY RESULTS 10. HIV TEST # Positive [ ] Negative[ ] 11. RPR TEST # POSITIVE [ ] Negative[ ] 12. HEPATITIS TEST # Positive[ ] Negative[ ] NAME OF TECHNICIAN SIGNATURE (Technician) Date

39

40 We need to change attitudes about AIDS. It is not the problem of the infected persons, like many people want to believe. It is everybody s problem. I have heard someone say, fear can hold you prisoner for the rest of your life, but hope can set you free. Hall J. (2002) Life Stories P 97 swaziland national aids/stds programme mbabane,swaziland december 2002