Integrating Sexual Health Services in Swaziland

"There are compelling arguments for integrating sexual and reproductive health and HIV/AIDS health services in Swaziland, but also a risk that it will discourage patients from seeking help..."

This news piece explores complexities associated with a strategy that has been levied in an attempt to address the high prevalence of both sexually transmitted infections (STIs) and HIV in Swaziland: integrating sexual and reproductive health and HIV/AIDS services. Ministry of Health figures indicate that almost 10% of the country's population - more than 100,000 people - were treated for STIs in 2008, and preliminary data from a population-based survey show that 26% of Swazis aged 15-49 years are HIV-positive (per the Joint United Nations Programme on HIV/AIDS, or UNAIDS).

To address these problems, at both public health facilities and those run by non-governmental organisations (NGOs), all patients who come for STI diagnosis, treatment, or any other reproductive health service are offered an HIV test, while patients in antiretroviral therapy clinics receive treatment for STIs. Authorities cited in the article indicate that the country's hospitals do less well in offering integrated services than the clinics, noting that the STI unit in a Swazi hospital is typically separate from the voluntary counselling and testing centre devoted to HIV/AIDS. Some advocate for stronger linkages; as one physician quoted here clarifies: "We're saying let the STI corner have HIV services such as testing and counselling with personnel trained to deliver all the services at one place. The first thing that comes to my mind when I see a patient with a sexually transmitted infection is that this person is not using protection therefore there is a high risk of exposure to HIV," she says, adding that STIs present an "entry point to start talking about HIV/AIDS". Some point out that the main infection prevention mechanisms are also similar (promotion of condom use, reduction in sexual partners, or promotion of abstinence).

But anecdotal evidence cited here suggests that the differences between STIs and HIV/AIDS may be as important as the similarities. Patients presenting with STI symptoms at the Family Life Association of Swaziland clinics are offered HIV/AIDS counselling and testing services at the same time and those who accept are given their results immediately. As reported here, despite this fact, roughly 40% of the patients refuse to test for HIV. This may be due to the fact that HIV/AIDS is a lifelong disease, whereas STIs tend to be acute and easily treatable. "Put simply, they would rather not know....In public health facilities, health workers are expected to offer HIV counselling and testing to all patients without the patient having to ask....[P]atients still have the right to refuse an HIV test, but there can be little doubt that the approach puts the pressure on, and may run the risk of discouraging people with STIs from coming in for treatment in the first place." Furthermore, "people who wish to know their HIV status may be discouraged from entering integrated units fearing the stigma associated with STIs." As one physician quoted here explains, "Can you imagine how much it would hurt the children, some of them teenagers now, who have been living with HIV since birth if HIV was considered an STI when some of them are not even sexually active?"

Finally, there is the question of the effect a push for greater integration will have on the male population. STI patients are given partner-tracing cards, which are effectively an invitation to the infected person's partner to come in for treatment. For men who have sex with men, the issue is difficult because homosexuality is illegal in Swaziland. Although the core mandate of the health sector is to provide equitable, non-discriminatory health services to all members of the general population irrespective of their sexual orientation and practices, communication challenges abound. Thus, as the author concludes, "It is perhaps only by changing attitudes that Swaziland will start to see a significant decline in its appalling HIV and STI statistics."