The first large-scale survey of Swazi homes to determine the impact of HIV/AIDS found a reversal of the decade-long trend of lower mortality rates, due to the pandemic. "Swaziland has entered uncharted territory", concluded the VAC's findings for 2003, released this week.
The VAC, which falls under the ministry of agriculture's National Disaster Relief Task Force, sought data to predict the effect of HIV/AIDS on future food production.
It discovered that homes burdened with the costs of caring for ailing family members, or the loss of breadwinners to AIDS, were now increasingly financially dependent on the sale of food grown in small family plots. In about 88 percent of Swazi households the proceeds from their domestic produce was the single largest source of income, followed by remittances from relatives with jobs in towns.
"There is a qualitative shift going on, whereby households affected by HIV/AIDS are changing their income sources to compensate for losses of income from crop sales", said the report.
Food aid was the main source of nutrition for rural residents in three of Swaziland's four regions, where drought has ruined harvests for the past three years.
In the northern Hhohho region, which was not as severely affected by drought and is more heavily urbanised and developed, food purchases were supplementing food aid.
The survey, taken before the introduction of antiretrovirals into the country, projected a yearly rise in mortality, reaching an annual total of 31,830 deaths due to AIDS in 2010. The incidence of deaths per 1,000 people rose from 11 in 1997 - almost on a par with the average of 10 per 1,000 in a developed country - to 20 per 1,000 in 2003. Infant mortality for the same period rose from 88 to 109 per 1,000.
"Previously declining mortality levels have increased markedly since the mid-1990s, reversing a positive trend of development. Mortality has increased dramatically among the age group 0 to 4 years, and in the previously healthy age group between 20 and 50 years, the report noted. Population growth in 2003 was two percent.
The report was based on a survey of 18,528 Swazi homes conducted by the Central Statistical Office (CSO) of the ministry of economic planning and development, with the support of UN agencies and NGOs. "The large number of respondents were felt necessary to give the study a strong statistical basis", Choice Ginindza, a senior statistician with the CSO, told IRIN.
It took nine months to complete the in-depth analysis of the most extensive survey yet undertaken in the small country.
"The study showed that females are suffering the brunt of the disease, with much higher levels of chronic illness and projected mortality", said VAC, and "the epidemic is changing mortality levels and patterns in a way that was not deemed possible a few years ago".
Other than a rise in AIDS-related deaths, the productive population group aged 24 to 45 years was most affected by the HI virus, rather than older Swazis.
"Deaths among infants and young children have also risen due to HIV/AIDS, mainly as a result of the transmission of the disease from mother to child", the researchers observed.
Information from secondary sources showed that the number of Swazis living in urban areas declined from 30 percent in 1997 to 25 percent in 2003.
"This affirms what we find anecdotally - that Swazis living in urban areas, who get sick from AIDS, return to their family's rural homestead to live out the rest of their shortened lives. This would explain a population shift from town to country," said Margaret Dlamini, an executive with the AIDS Support Centre, a testing and counselling facility in the central commercial town of Manzini.
AIDS had also dramatically impacted the age dependency ratio, which looks at how many children under 14 and elderly persons over 65 depend on an economically productive family member. Although AIDS mortalities have cut into the number of breadwinners nationwide, the survey found that the dependency ratio had decreased (or improved) substantially since 1986, when an average 125 persons depended on 100 productive people, to 90 persons in 2003 - a 27 percent decline. Developed countries have an average of 50 to 60 dependents per 100 productive persons.
The study pointed to lower fertility rates, combined with higher AIDS-related infant mortality, as the cause for the dependency decline.
Some health officials have found fault with the survey, which does not factor in the effect of antiretroviral drugs on future life spans and AIDS mortality.
"The survey uses chronic illnesses as a proxy for AIDS - this is problematic methodology," the director of one social welfare NGO told IRIN. "Because no one will admit that a family member has AIDS, it was taken that any person with a chronic illness has AIDS. But what of cancer or tuberculosis, which was rampant in Swaziland before AIDS? The methodology undermines the statistical validity of the results."
In the absence of "large-scale expensive national testing for HIV/AIDS, this survey used proxy indicators, such as chronic illness among age groups 19 to 49, as the next best way to ascertain probable HIV/AIDS prevalence", said Alex Rees, an advisor with VAC.
"The age group between 19 and 49 years is normally very healthy, with low levels of illness and death. Incorporating persons with other illnesses, such as cancer or heart disease, in the statistics is possible, but levels are judged to be very low. The use of proxy indicators also provides those interviewed with confidentiality, which is important when stigma to HIV/AIDS plays such a damaging role in society," Rees explained.
The ministry of health is planning a nationwide household health survey, beginning in June, in which respondents will be asked if they or any household members have HIV. Blood tests will be taken as substantiating evidence.
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