HIV/AIDS in Eswatini was first reported in 1986 but has since reached epidemic proportions. As of 2016, Eswatini had the highest prevalence of HIV among adults aged 15 to 49 in the world (27.2%).
The HIV/AIDS epidemic in Eswatini has contributed largely to high mortality rates among productive Swazi age groups. Over the long-term, the epidemic and its respondents induced major cultural changes surrounding local practices and ideas of death, dying, and illness, as well as an expansion of life insurance and mortuary service markets and health-related non-governmental organizations.
To help Eswatini and other countries across the world address HIV and AIDS, the Joint United Nations Programme on HIV/AIDS (UNAIDS) developed the 95-95-95 testing and treatment targets. Local and national efforts worked towards the following three goals by 2020: 90% of people living with HIV will be aware of their HIV-positive status; 90% of those who have been diagnosed with HIV will continuously and consistently receive antiretroviral therapy (ART); and 90% of all people who are receiving ART will have viral suppression.Joint United Nations Programme on HIV/AIDS (UNAIDS). (2014). 90-90-90: An ambitious treatment target to help end the AIDS epidemic Although Eswatini has nearly achieved the testing and treatment targets of the 90–90–90 model, certain populations carry a disproportionate burden.U.S. President's Emergency Plan for AIDS Relief. (2018). Swaziland Country Operational Plan (COP) 2018 Strategic Direction Summary. The U.S. President's Emergency Plan for AIDS Relief (PEPFAR) has identified priority and key populations as the most vulnerable to HIV infection, due to epidemiological, socioeconomic, and environmental and contextual factors. In particular, PEPFAR identified three priority populations in Eswatini as the focus of HIV/AIDS prevention and treatment programs: adolescent girls and young women (aged nine to 29), men aged 15 to 39, and orphaned and vulnerable children (OVC). PEPFAR additionally identified three key populations: men who have sex with men (MSM), female sex workers (FSW), and transgender people. PEPFAR support was abruptly cut back in 2025, causing some people to go without HIV testing or treatment.
Overall prevalence of HIV/AIDS
HIV/AIDS remains one of the major challenges to Eswatini's socioeconomic development. In 2010, "the Ministry of Labour and Social Security estimated 43 percent of the population were "inactive workers"—students, the elderly, the ill, the disabled, people who "lack capital" or "look after" their own "need"—and not part of the formal labor force."
Periodic surveillance of prenatal clinics in the country has shown a consistent rise in HIV prevalence among pregnant women attending the clinics. The most recent surveillance in antenatal women reported an overall prevalence of 42.6% in 2004. Prevalence of 28% was found among young women aged 15–19. In women ages 25–29, prevalence was 56%."Health Profile: Swaziland" . United States Agency for International Development (June 2005).
The Human Development Index from the UN Development Programme reports that as a consequence of HIV/AIDS, life expectancy in Eswatini has fallen from 61 years in 2000, to 32 years in 2009. From another perspective, the last available World Health Organization (WHO) data (2002) shows that 64% of all deaths in the country were caused by HIV/AIDS.Swaziland, Mortality Country Fact Sheet 2006. WHO. . Accessed November 22, 2009 In 2009, an estimated 7,000 people died from AIDS-related causes.UNAIDS Report on the global AIDS epidemic 2010 Annex 1 - HIV and AIDs estimates and data, 2009 and 2001. UNAIDS. . Accessed October 6, 2011 On a total population of approximately 1,185,000World Population Prospects: 2008 Revision. United Nations. http://www.un.org/esa/population/publications/wpp2008/wpp2008_text_tables.pdf. Accessed October 6, 2011 this implies that HIV/AIDS kills an estimated 0.6% of the Swazi population every year. Chronic illnesses that are the most prolific causes of death in the developed world only account for a minute fraction of deaths in Eswatini; for example, heart disease, strokes, and cancer cause a total of less than 5% of deaths in Eswatini, compared to 55% of all deaths yearly in the US.Causes of death in US, 2006. CDC. https://www.cdc.gov/nchs/data/nvsr/nvsr57/nvsr57_14.pdf. Accessed November 22, 2009.
The United Nations Development Program has written that if the spread of the epidemic in the country continues unabated, the "longer term existence of Eswatini as a country will be seriously threatened".Country programme outline for Swaziland, 2006-2010. United Nations Development Program. http://www.undp.org.sz/index.php?option=com_docman&task=doc_download&gid=19&Itemid=67 . Accessed November 22, 2009
History The first reported case of HIV in Eswatini was in 1986 in the Times of Swaziland newspaper. The spread of HIV throughout Eswatini in the 1980s and 1990s coincided with the increase of migrant workers from Eswatini to the mines of South Africa. "Researchers, health care and public health specialists, and policymakers all lobbied for state action since the late 1980s; the Ministry of Health established the Swaziland National AIDS Programme (SNAP) in 1987. Vusi Matsebula and Thulasizwe Hannie Dlamini registered their Emahlahlandlela (Pioneers) grassroots AIDS support group, the first in the country, as SASO, the Swaziland AIDS Support Organisation, in 1994. The year before, Hannie Dlamini publicly stated that he was HIV positive, the first person to do so in the country. Swazi women scholars Mamane Nxumalo and Phumelele Thwala were some of the first to write critically about HIV/AIDS in Swaziland, discussing how gender-unequal practices played a role in disease transmission," and "by the time SASO opened their first office in Mbabane in 1998, the national incidence rate was estimated to be 5.5 percent."
Finally, King Mswati III of Eswatini declared HIV/AIDS to be a national disaster in Eswatini in February 1999."AIDS in Swaziland", Radio Netherlands Archives, July 10, 2000 By 1999, "there were an estimated 112,000 OVCs [orphaned and vulnerable children], almost a quarter of all children in the country; the Ministry of Education reported losing four teachers a week to AIDS-related illness, and business owners feared foreign investment losses due to decreased productivity in sick workers' absenteeism. The Ministry of Health and Social Welfare was not able to fully finance public treatment. Even working with the Joint United Nations Programme on HIV/AIDS (UNAIDS) and local NGOs, they were all structurally outpaced."
Cultural background Regionally, there are many indigenous cultural practices that encourage abstinence and gender-segregated sexual and social education for youth, the avoidance of premarital penetrative heterosexual contact, and the avoidance of public lascivious behavior (i.e. displaying penile erections).
In part, certain proponents of aspects of what is called 'traditional Swazi culture' discourage safe sexual practices, like condom use and monogamous relationships. Very few men today practice the cultural ideal of polygamy. Sexual aggression is common, with 18% of sexually active high school students saying they were coerced into their first sexual encounter.
National response In 2003, the National Emergency Response Committee on HIV/AIDS (NERCHA) was established to coordinate and facilitate the national multisectoral response to HIV/AIDS, while the Ministry of Health and Social Welfare (MOHSW) was to implement activities. The previous national HIV/AIDS strategic plan covered the period 2000–2005; a new national HIV/AIDS strategic plan and a national HIV/AIDS action plan for the 2006–2008 period are currently being developed by a broad group of national stakeholders. To date, the six key areas of the plan are prevention, care and support, impact mitigation, communications, monitoring and evaluation, and management/coordination.
Despite the widespread nature of the epidemic in Eswatini, HIV/AIDS is still heavily stigmatized. Few people living with HIV/AIDS, particularly prominent people such as religious and traditional leaders and media/sports personalities, have come out publicly and revealed their status. Stigma hinders the flow of information to communities, hampers prevention efforts, and reduces utilization of services.
On June 4, 2009, the US and then-Swaziland signed the "Swaziland Partnership Framework on HIV and AIDS for 2009–2014". The President's Emergency Plan for AIDS Relief (PEPFAR) will contribute to the implementation of Eswatini's multi-sectoral "National Strategic Framework on HIV/AIDS". The plan was reconducted with a new eNSF (National Strategic Framework) for 2014–2018.
Various community responses have been implemented as a result of this plan, consisting in the implementation of a decentralised coordination. For example, the formation of 3 regional and community structures, including Nhlangano AIDS Training Information and Counseling Center in the Shiselweni Region.
The 2015 ART treatment guidelines from the Ministry of Health "mandate that after a test, patients are given HIV information in simple terms to "clarify misconceptions and myths." They are also counseled on good nutrition, risk reduction, and where to get more information about HIV. If they test positive, they are reassured "that they can live a long healthy life." ARVs are immediately commenced with seropositive patients who: have CD4 counts of 350 or less; are over age fifty or under age five; pregnant; have tuberculosis; and/or have a serodiscordant partner, namely a partner who is HIV negative. Opportunistic infections are treated before ART."
In 2025, PEPFAR support was cut back as part of the second Trump Administration's dismantling of USAID. Eswatini had targeted financial self-sufficiency of its HIV/AIDS response by 2030, but the abrupt cutoff resulted in staff firings and some people going without HIV testing or treatment.
HIV/AIDS-related disparities Although Eswatini's multisectoral response to HIV and AIDS has obtained positive results, HIV/AIDS prevalence continues to be higher and access to prevention programs continues to be lower in rural populations compared to urban populations, as well as in economically disadvantaged populations compared to economically advantaged populations.
Rural versus urban populations The United Nations International Children's Emergency Fund (UNICEF) estimated that, from 2009 to 2013, 70% of urban females aged 15 to 24 had comprehensive knowledge of HIV/AIDS.UNICEF (Ed.). (2014). Reimagine the future: innovation for every child. New York, NY: UNICEF. Only 55% of rural females in the same age group from 2009 to 2013 had access to HIV/AIDS-related knowledge. Still, given the relatively small size of the country, nearly all citizens are connected by family and social networks and often move between urban and rural areas.
Economically disadvantaged versus economically advantaged populations Data from 2009 to 2013 revealed that, out of the poorest 20% of females aged 15 to 24 in Eswatini, 49% had comprehensive knowledge of HIV/AIDS. In comparison, 72% of the richest 20% of females from the same age group had comprehensive knowledge of HIV/AIDS.
The gap observed among rich and poor males is comparable to the gap in comprehensive HIV/AIDS knowledge among rich and poor females from 2009 to 2013: 44% of the poorest 20% versus 64% of the richest 20% of Swazi males aged 15 to 24 had comprehensive knowledge of HIV/AIDS.
Men aged 15 to 39