Cultural Barriers Are Preventing Women in Eswatini From Accessing HIV Care

Colleta DewaDec. 5, 2022

Partipciants in the Umhlanga Reed Dance festival in Lobamba, Eswatini, in August 2016. At the festival―which celebrates chastity―the king, who has 15 wives and 36 children, is traditionally expected to pick a new fiancé.Getty Images/Andalou Agency

Eswatini (formerly Swaziland), a tiny country of just over a million people in Southern Africa, has one of the highest HIV prevalence rates in the world. As of 2021, UNAIDS reported that 27.9% of people aged 15-49 within the country are living with the virus.

According to the Global Fund―an international financing partnership that works to eliminate HIV, tuberculosis, and malaria―63% of the people living with HIV (PLWH) in the country are women, who continue to be disproportionately affected by the virus. For example, the fund reported that in 2020, women and girls accounted for 63% of all new HIV diagnoses.

The Normalization of Violating Women in Eswatini

While the epidemic is generalized, it is women who bear the brunt of infections and socioeconomic consequences. Individuals who live in rural areas or who have had less access to formal schooling are at highest risk.

“Things were hard at home,” Nosiziba Kunene told TheBody. “We could not afford to have a decent meal every day. My parents had no land to farm. One of our neighbors offered to sell us a piece of his land. Unfortunately, my father had no money to pay for it. They made an agreement to give me as a wife to the 52-year-old [landowner]. I was only 14 years old then. The arrangement was made without my consent.”

Kunene, who is now 26 years old, is one of many girls and women in the landlocked kingdom who are entrapped within the social confines of cultural norms, which can, directly and indirectly, expose them to acquiring HIV or other sexually transmitted diseases (STIs). Most of these outdated practices promote child marriages, wife inheritance, and polygamy, which in turn reduces the possibility of safer sex.

Led by King Mswati III, the last absolute monarch in Africa, Eswatini also prides itself on cultural festivals and traditional ceremonies that are celebrated religiously.

From a distance, these events may look glamorous to some. Especially the renowned Umhlanga Reed Dance festival―which celebrates chastity as well as virginity―wherein the king, a polygamist with 15 wives and 36 children, is traditionally expected to pick a new fiancé from among the thousands of girls that grace the occasion.

“By the time my father forced me to marry our neighbor in exchange for land, I was already deflowered,” Kunene explained while discussing the festival. “I had attended the reed dance the previous year, and I was raped while in camp preparing to participate. The man who raped me was one of the security guys who were supposed to be taking care of us.

“Being forced to marry the 52-year-old man only added salt to a wound that had not and will never heal [the rape],” she continued. “I dropped out of school to be his fourth wife. My dreams of becoming a lawyer were shuttered. Seven years into the marriage, I already had three children. That’s when I made up my mind and ran away. By that time, I was already diagnosed with HIV and my husband was denying me consistent access to medical attention.”

Eswatini Has a Deeply Male-Dominated Society, and Violence Against Women Is Widespread

In Swazi culture, decision-making has traditionally been a male prerogative. Women suffer discrimination, are treated as inferior, and are denied rights. Because family-planning decisions are made by men, women are subjected to continuous childbirth by their husbands and in-laws, against their will.

According to a report published by UNICEF in 2009, one in three girls in Eswatini experienced sexual violence before the age of 18. About 14% of girls experienced rape or coerced sex (for example, through intimidation or threats) before age 18. One in six girls ages 13 to 17 had experienced sexual violence in the past year. The body was unable to locate any substantial follow-ups on this study since it was first conducted.

“It is a mess,” Nonhlanhla Dlamini explained to TheBody. “Older emaSwati males purposefully deflower little girls, which results in teenage pregnancies and exposes young girls to the risks of contracting sexually transmitted infections and the HIV virus. When the girls fall pregnant, they are forced into early marriages, dumped, their dreams are shattered and futures destroyed as they drop out of school.”

Dlamini is an activist and the director of the Swaziland Action Group Against Abuse (SWAGAA), a women-led, women’s rights organization that coordinates violence-prevention activities, provides comprehensive care and support services, and advocates for legal and policy reform. It also works to influence social norms and facilitate survivors’ access to justice by fostering safe environments and developing agency among women and girls.

According to Dlamini, objectifying young women and subjecting them to the tribal fetishes of old men does not conform to the sacred and common principles of dignity and human rights that society should promote and protect.

Struggling to Shift Cultural Practices

The battle against cultural practices that expose women and make them vulnerable to unsafe sexual behavior is far from being won in Eswatini. Convincing traditional leaders to change has often felt impossible.

Behavioral change plays a crucial role in any strategy that aims to reduce HIV incidence. Additionally, the larger social environment must be taken into account for any national program that seeks to combat a disease that is so entwined with social and economic factors.

In the Mbilaneni community, headman (patriarchal leader) Simeon Malinga told TheBody that no one has the right to challenge their practices. “Polygamy is a tradition that we found existing. It was used since way back; we cannot change or challenge it. Even my father had four wives. I had two wives. One died, and I’m now left with one.”

He added, “It is a woman’s duty to procreate. Women were created for that, and it is a man’s responsibility to have as many children as possible as a sign of strength.”

Dlamini believes that as the world continues to modernize, it should be everyone’s concern that culture and customs not be used to abuse or encourage human rights violations.

“What is encouraging is the fact that many civic organizations are now rising against such social ills in the country,” Dlamini said, while focusing on a way forward. “We respect traditionalists but will challenge any culture that compromises the health of the next person. Eswatini needs an all-inclusive culminating activism strategy in order to uproot the rampant abuse of women.”

Another group that is advocating for abolishing unfair marital setups that endanger women’s health is the Umvemve Women Conference (UWC)―a women’s empowerment group that is based in Nhlangano, the fourth largest town in the country.

While speaking to TheBody about her concern with the “backward and oppressive” culture of wife inheritance, the group’s chairperson Gugu Mathobela noted, “It is only in Eswatini where even death cannot separate a woman from her husband. If one’s husband dies, the widow is quickly taken in by the deceased’s brother, in a culture known as Kungenwa [wife inheritance]. [If this] culture is dynamic, why are emaSwati leaders failing to adjust and tailor their approaches to be culturally sensitive and change in response to the spread of the HIV virus?”

Building a Way Forward

Both UWC and SWAGAA are working with several international organizations such as the United Nations and Doctors Without Borders/Médecins Sans Frontières (MSF) to help empower women and girls living with HIV.

Kunene is one of the beneficiaries of these activities and has also become a volunteer, campaigning to raise awareness and to encourage women to get tested and to take antiretroviral treatment (ART) as it is prescribed.

“When I ran away from the marriage, I was introduced to SWAGAA,” she said. “I joined the organization. They helped facilitate an easy platform for us to get free medical assistance and drugs from MSF.”

Bernhard Kerschberger, M.D., Ph.D., the head of mission in Eswatini for MSF, told TheBody that the organization has made significant progress in improving the number of people receiving ART.

“In Eswatini we are emphasizing a multisectoral response that focuses on key behaviors that influence the spread of HIV,” he explained. “Reduction of multiple concurrent partnerships, delaying sexual debut, and increasing condom use are key components. Most people in the country are reluctant to get tested, while most women have been denied medical care due to various customary reasons. Stigma and fear are also making the response difficult.

“At MSF, we however continue to help more HIV patients access ARV treatment through the ‘test and start’ strategy. A team has been piloting ‘test and start’ in the Nhlangano project; after HIV testing, ARV treatment was offered to more than 1,700 people after a positive HIV diagnosis to immediately start treatment.” Kerschberger noted that MSF has also expanded its approach to include community-based models of care, in order to provide better treatment access to patients in rural areas.

“It is important to consider the particular needs of the people here to ensure there is as little as possible negative impact on their health [and] on the ability to provide health care, so the country can maintain the gains made in fighting HIV and TB.”

MSF is also integrating self-care, including pre-exposure prophylaxis (PrEP), as part of a patient-centered approach to health care by providing people with the knowledge, skills, and tools to take charge of their own wellness.

Similarly, UNAIDS has been promoting activities aimed at caring for children who have been orphaned due to HIV/AIDS. The organization has done so with cultural sensitivity by revamping KaGogo safety centers.

Once upon a time, the KaGogo (literally “grandmother’s house”) was an integral part of every Swazi homestead. It functioned as a place of refuge or a neutral site for discussing family matters and resolving disputes. Now the spirit of KaGogo has been integrated into mobilizing the communal HIV response.

“KaGogo social centers serve as a meeting place for orphaned children where HIV prevention, care, and support activities can take place,” a UNAIDS representative told TheBody. “Often centers are doubling up as Neighborhood Care Points, where education and food are provided.”

Despite Struggles, There Is Progress

In response to TheBody’s questions on the issue of tradition and its impact on women’s health in the country, Senator Lizzie Nkosi, minister of health of Eswatini, said, “Government is now focusing on the positive side. We are hopeful and grateful to have reached the epidemic control and the 95-95-95 targets.”

In 2020, Eswatini and Switzerland became the first countries in the world to reach this target. That means that 95% of people living with HIV in Eswatini know their status, 95% of people who know their seropositive status are accessing treatment and 95% of people on treatment have suppressed viral load. But attaining this goal has yet to shift the disproportionate rate of HIV diagnoses among women.

When asked about this, the minister neither confirmed nor denied the need for a cultural paradigm shift in controlling the spread of the HIV virus.

Despite the hurdles that SWAGAA continues to face, it is one of the country’s most successful organizations that fight for Eswatini women’s rights and advocates for PLWH.

“The battle [with addressing sexual violence] started with police officers’ attitudes,” Dlamini explained. “We would advocate for survivors and request that the police provide privacy. But they didn’t see why [survivors] wouldn’t report over the counter. It took many workshops to demonstrate how a rape case differed from, say, a burglary, and how each case deserved different treatment. At the time, there was scant public trust in SWAGAA, which was seen as interfering with family issues.”

Dlamini and the organization were active in the push for stronger legal protections for women. In fact, she was part of the committee that drafted the Sexual Offences and Domestic Violence Act bill (SODV) and pushed it until it became law in June 2018. This law elevated the rights of women, changed some of the definitions of sexual crimes, made all forms of sexual exploitation and abuse a crime, expanded access to medical care for survivors, and reduced barriers to justice.

Dlamini told TheBody that she is proud of the law, which she was part of from its first draft proposals. She added, “It is our hope for a better legal perspective with regards to sexual abuse of women.”

SWAGAA has also successfully advocated for child-friendly courts―the first one was set up in the capital city Mbabane―as well as the establishment of three one-stop centers. The idea behind these centers was borrowed from South Africa’s Thuthuzela centers, where health care; counseling services; legal aid; and clothing, food, and housing to support survivors are under one roof. Although breakthroughs are being made in making homes and communities safe for women and in the provision of ART for PLWH, extreme poverty remains a stumbling block.

Kunene explained that while MSF has made it possible for PLWH to access free ART, “most people living with the virus are incapable of getting appropriate nutritious food.” She said that UNAIDS’ Ndlunkulu fields program―which sets aside a portion of land for those in need, to combat food insecurity―has been helpful in addressing this issue.

All of this highlights the need for sustainability and cultural reform. Because even after abuse against women and access to ART have been resolved, they will still need economic opportunities―in a male-dominated country that prohibits them from working in many sectors―to stay afloat.