State of the Epidemic: Swaziland, Lesotho and Zimbabwe

Posted in: News, News 2018
Phill Wilson, President and CEO, Black AIDS Institute.

Some parts of the world have seen a dramatic decrease in HIV/AIDS diagnoses. However, other regions have struggled. Africa has been the continent most impacted by the epidemic. During April 2018, BAI President and CEO Phill Wilson has been conducting training in Swaziland, Lesotho and Zimbabwe.  Here, we provide an overview of the epidemics in these African nations, which have been particularly hard hit.


Swaziland has the highest prevalence of HIV in the world. In 2016, there were 220,000 people living with HIV (PLWH)—a whopping 27.2 percent of adults in the country. That year, there were 8,800 new infections and 3,900 AIDS-related deaths.

The biggest driver of the epidemic in Swaziland is heterosexual sex, and women are disproportionately affected. According to UNAIDS, in 2016, 34.7 percent of women between the ages of 15 and 49 were living with HIV, compared with 19.6 percent of men between 15 and 49.  There are a number of reasons contributing to this fact:

  • Gender-based violence and abuse are common, so women may not feel comfortable refusing sex or insisting on condom usage.
  • Young women are likely to be sexually involved with men who are significantly older than they are, so there is often an imbalance of power in the relationship.
  • As many as 12 percent of women between the ages of 15 and 49 are in a polygamous marriage, increasing their risks of acquiring HIV.

There is little data about the epidemic among men who have sex with men (MSM), possibly because homosexuality is illegal. There are also fewer efforts to target gay and bisexual men with education and programs that can prevent transmission than other at-risk populations. A study by UNAIDS (pdf) estimated that 12.6 percent of MSM were living with HIV in 2016.

Swaziland has the highest prevalence of HIV among sex workers in the world, with 60.5 percent believed to be living with HIV in 2016.

The good news is that Swaziland is making progress to fight the epidemic. In 2014, the country adopted guidelines by the World Health Organization (WHO) that recommend that anyone diagnosed with HIV be treated with antiretroviral (ARV) medications, regardless of their CD4 count. Since 2003, ARV treatment has also been free in Swaziland and funded entirely by the government, so people don’t have to worry about insurance or expensive medications. In 2016, 79 percent of people in Swaziland who were living with HIV were on ARVs, according to UNAIDS.


Lesotho is right behind Swaziland with the second-highest prevalence of HIV in the world. In Lesotho, there were 330,000 PLWH in 2016—25 percent of the adult population. There were 21,000 new infections that year and 9,900 AIDS-related deaths.

As with Swaziland, women are disproportionately at risk of acquiring HIV. In fact, the prevalence among women rose from 26 percent to 30 percent (pdf) between 2004 and 2014. During that same decade, the prevalence among men remained the same at 19 percent. Gender-based violence and a patriarchal society may be partly to blame because women may not have power in the relationship to negotiate condom usage and other safer sex practices.

Many young women in Lesotho work as factory workers, and the garment industry is located in Leribe and Maseru—two districts that have a high prevalence of HIV. It’s estimated that 42.7 percent of factory workers have HIV.

Because homosexuality is illegal, there is limited information on the extent to which gay and bisexual men are affected by HIV in Lesotho. A 2015 report (pdf) by the Lesotho Ministry of Health estimated that between 31 percent and 35 percent of MSM in two particular areas (Maseru and Maputsoe) had HIV.

Finally, sex workers are disproportionately affected, with 79.1 percent of them living with HIV in 2015.

In 2016, Lesotho adopted WHO guidelines for a “Test and Treat” strategy. As a result, any person in Lesotho who tests positive for HIV will be given the option of taking ARVs. A survey taken between November 2016 and May 2017 found that 67.6 percent of PLWH in Lesotho experienced viral-load suppression. Of those PLWH who knew their HIV status, 90.2 percent reported that they were in treatment.


In Zimbabwe, new HIV infections have fallen in the last decade, but much work remains to be done. There were 40,000 new infections in 2016, down from 79,000 in 2010. However, that same year, there were 1.3 million people in Zimbabwe living with HIV, and Zimbabwe had the sixth-highest prevalence of HIV in sub-Saharan Africa at 13.5 percent.

In Zimbabwe, women are disproportionately affected, with 720,000 women living with HIV as of 2016, according to UNAIDS.  Gender inequality plays a role. Many women don’t have power in their intimate relationships, so their ability to negotiate safe sexual practices may be limited.

Approximately 35 percent of married women have experienced physical or sexual violence from a spouse, according to the 2015 Zimbabwe Demographic and Health Survey (pdf). Perhaps even more troubling, only 63 percent of women and 69 percent of men in Zimbabwe believe that a woman has a right to refuse sex with her husband if he has had sex with other women. Thirteen percent of women and 15 percent of men believe that a wife does not have the right to ask her husband to use a condom even if she knows he has a sexually transmitted infection (STI).

Sex workers are also heavily impacted by HIV. In Zimbabwe, they have an HIV prevalence of 57.1 percent, UNAIDS says. A study published in 2017 in the Journal of Acquired Immune Deficiency Syndrome found that 64 percent of female sex workers in Zimbabwe were aware of their status, while 36 percent were not.

In Zimbabwe, homosexuality is illegal for men, yet it is legal for women. Gay and bisexual men who fear being prosecuted may avoid seeking out services such as HIV testing because of fears of stigma and discrimination. In fact, according to UNAIDS, only 14.1 percent of Zimbabwe’s MSM even knew their HIV status in 2016.

Zimbabwe adopted a National HIV and AIDS Strategic Plan in 2011, which placed emphasis on education, voluntary male circumcision, condom usage, STI management and dispensing ARV drugs to pregnant women to decrease the risk of mother-to-child transmission. Though the plan came to an end in 2015, the same targets remain in place.

In 2015, 80 percent of girls and women between the ages of 15 and 49 had been tested for HIV and received the results of their test, according to the Demographic and Health Survey. That’s up from 22 percent of women in 2006 and 58 percent in 2011. In 2015, 62 percent of men had been tested and received the results of their test. Only 16 percent of men had been tested in 2006. In January 2018, between 2,000 and 2,500 people were estimated to be taking pre-exposure prophylaxis (PrEP).

Tamara E. Holmes is a Washington, D.C.-based journalist who writes about health, wealth and personal growth.