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

By Phakathi, Mantoe | Bulletin of the World Health Organization, November 2009 | Go to article overview

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


Phakathi, Mantoe, Bulletin of the World Health Organization


Almost 10% of the population of Swaziland--more than 100 000 people--were treated for sexually transmitted infections (STIs) in 2008, according to Zandile Mnisi, STI programme coordinator at the Swaziland Ministry of Health. Alarming in itself, the number is also indicative of prevailing high-risk sexual practices in a country that has the highest HIV prevalence in the world. According to a UNAIDS report, preliminary data from a population-based survey show that about one in four (26%) Swazis aged 15-49 years is HIV positive.

Swazi authorities are trying to address these problems by pushing for greater integration of the sexual and reproductive health and HIV/ AIDS services offered in hospitals and clinics. This is done by providing STI services at all entry points in the health facilities, Mnisi explains. "For example, pregnant women who come for antenatal care services are screened and treated for STIs, and the same goes for women who come in for family planning services. Children who are brought in for growth monitoring are also examined for the presence of STIs and treated if any are detected."

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There is already a degree of integration in this area. Dudu Simelane, director of the Family Life Association of Swaziland, a nongovernmental organization that provides reproductive health care services, says that all patients who come for STI diagnosis, treatment or any other reproductive health service are offered an HIV test, while patients in Swaziland's antiretroviral therapy clinics receive treatment for STIs. This is true both for public health facilities and those run by nongovernmental organizations.

The country's hospitals do less well in offering integrated services than the clinics. "As a country we have a challenge in the integration of services, both in the approach and delivery," says Rejoice Nkambule, deputy director of Health Services (Public Health) at the Ministry of Health, noting that the STI unit in a Swazi hospital is typically separate from the voluntary counselling and testing centre devoted to HIV/ AIDS. Nkambule would like to see this change, but is aware of the challenges notably the problem of increased waiting times for patients in units offering a broader range of services, and the risk of health worker burnout.

For Dr Velephi Okello, medical practitioner and national coordinator of the HIV/AIDS treatment programme at the Ministry of Health, improving integration need not be a painful process. "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," she says, pointing out that the different services combine quite naturally anyway. "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". This viewpoint is shared by Simelane, who says that the main infection prevention mechanisms are also similar--promotion of condom use, reduction in sexual partners or promotion of abstinence.

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But is it really that simple? Anecdotal evidence suggests that it might not be, and that the differences between STIs and HIV/AIDS are as important as the similarities. One of the most obvious differences concerns prognosis. HIV/AIDS, while no longer necessarily a death sentence, is still certainly a lifelong disease, whereas STIs tend to be acute and easily treatable. Patients are well aware of this difference and it influences their choices, according to Letticia Bennett, senior nursing sister at the Family Life Association of Swaziland.

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. …

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