AIDS in Africa - Botswana
The History of HIV/AIDS in Botswana
What is happening now?
HIV and AIDS treatment and care
The Way Forward
Botswana is one of the countries that has been
hardest hit by the worldwide HIV epidemic. In 2004 there were an
estimated 260,000 people in Botswana living with HIV, or 350,000
according to a UNAIDS estimate for the end of 2003. This, in a
country with a total population of 1.6 million, gives Botswana a
prevalence rate of 36.5%, the second highest in the world after
Swaziland.1 Life expectancy is only 39 years, while it would have
been 72, if it were not for AIDS2. There are around 60,000
registered orphans in the country but it is feared that Botswana
will have about 200,000 orphans in 2010 if the current situation is
not reversed.3 In an address to the UN General Assembly in 2001, the
President of Botswana, Festus Mogae, said 'we are threatened with
extinction. People are dying in chillingly high numbers. It is a
crisis of the first magnitude.
Botswana has become the first African country to aim
to provide antiretroviral therapy to its citizens on a national
scale. It is believed by many that if any country in Africa is going
to succeed in implementing such a comprehensive HIV/AIDS care and
treatment programme, then it is Botswana. The country has enjoyed a
period of unbroken peace since 1966 and has become relatively
prosperous due to its diamond mines. The annual per capita income is
US$3,300, amongst the highest in the area.
Botswana's first AIDS case was reported in 1985.
Then AIDS was seen as a disease that affected male homosexuals in
the West and people from other African countries.
Botswana's response to the HIV and AIDS epidemic can
be divided into three stages. The early stage (1987-89) focused
mainly on the screening of blood to eliminate the risk of HIV
transmission through blood transfusion. The second stage (1989-97),
and the first Medium Term Plan (MTP), saw the introduction of
information, education and communication programmes, but the
response was still fairly narrowly focused. During this stage, in
1993, the government adopted the Botswana National Policy on AIDS.
During the third stage (1997-2002), the response to
HIV/AIDS was expanded in many different directions to include
education, prevention and comprehensive care including the provision
of antiretroviral treatment. The aim of this plan (known as MTP II)
was to involve many stakeholders who had previously been excluded,
with the overall aim, not only of reducing HIV infection and
transmission, but also reducing the impact of HIV and AIDS at all
levels of society.
The National AIDS Co-ordinating Agency (NACA) was
set up in 2000 and was given responsibility for mobilising and co-ordinating
a multi-sectorial national response to HIV and AIDS. NACA is chaired
by the President and is also the secretariat for the National AIDS
There are many different HIV/AIDS initiatives and
programs now taking place in Botswana. One of the most high profile
initiatives is the African Comprehensive HIV/AIDS Partnerships (ACHAP).
ACHAP is a collaboration between the Government of Botswana, the
Bill & Melinda Gates Foundation and the Merck Company Foundation.
ACHAP was established in July 2000 with the aim of supporting the
goals of the Botswana Government in decreasing HIV incidence and
significantly increasing the rate of diagnosis and treatment of the
disease by rapidly advancing prevention programmes, health care
access, patient management and the treatment of HIV/AIDS. In
November 2003, Tsetsele Fantan took over from Donald de Korte as the
new ACHAP project leader. Talking about her new post, she emphasised
the importance of partnership and national unity in combating AIDS
and achieving the goal of a nation free of AIDS in 2016.
The Bill and Melinda Gates Foundation and the Merck
Company Foundation have each committed $50 million over five years
towards the project. Merck & Co., Inc. is also donating two
There are a number of different prevention programs
currently taking place in Botswana. These include:
• Public education & awareness
• Education for young people
• Condom distribution & education
• Prevention of mother to child transmission (MTCT).
Public awareness and education has previously been
based on the "ABC" of AIDS: Abstain, Be faithful, if you have sex,
Condomize. Botswana has safe-sex billboards and posters everywhere,
but it is unclear whether anyone pays attention.
"This country has been bombarded with HIV messages,
but there hasn't been a change in behaviour".
So now the aim is to target the right message to the
right people9. One recent initiative has been the development of
more than 100 episodes of a radio drama, Makgabaneng, dealing with
culturally specific HIV/AIDS-related issues and encouraging changes
in sexual behaviour. Another initiative has involved workplace peer
counselling, including the development, piloting and distribution of
a facilitator's manual.
To provide young people with HIV/AIDS prevention and
education is crucial. Prevention efforts in Botswana have included
supporting the Youth Health Organisation (YOHO). YOHO is a youth-run
non-governmental organisation (NGO) that aims to provide other young
people with sex education. HIV/AIDS-related education at school
plays one of the most important parts in educating young people
about HIV and AIDS, and Botswana-specific HIV/AIDS materials have
been developed for students with the Ministry of Education.
A teacher-capacity building programme has been
developed jointly by the Ministry of Education of Botswana and the
United Nations Development Programme (UNDP), in collaboration with
the government of Brazil and with support from ACHAP. The programme
is trying to improve the teachers' knowledge, demystify and
destigmatise HIV/AIDS and break down cultural beliefs about sex and
sexuality. It is hoped that this will promote free and informative
discussions about HIV prevention, living with HIV/AIDS and caring
for adults and children with, or directly affected by HIV/AIDS.
There has been successful social marketing of
condoms in Botswana, and this has included a launch of both male and
female condoms and making condoms a commonly available product. One
of Botswana's key marketing strategies of condoms has been peer
education, with peer education being conducted in a variety of
creative settings such as in schools, at fairs and festivals,
shopping malls, workplaces and bars.
ACHAP, the University of Botswana and Population
Services International (PSI) undertook an extensive condom market
research campaign to find out national attitudes towards sex and
condom use. The results suggested a need for the increased marketing
of condoms and distribution outlets. In response, the government
with funding and technical support from ACHAP is going to initiate
nationwide installation of 10,500 condom dispensers, thus providing
free condoms to the public. In 2002, the National AIDS Coordinating
Agency (NACA) conducted an HIV/AIDS awareness survey and found out
that in the 15-49 age group, condom use at last act with a
non-marital or non-cohabiting partner was 70% for women and 77.5%
USAID, the African Youth Alliance, Botswana National
AIDS Service Organisation (BONASO) and NACA, seven ministries, the
defence force, the police force, the university of Botswana, the U.S
Centre for Disease Control (CDC) and ACHAP are initiating a
prevention programme that will be linked to the Corridors of Hope
project. The Corridors of Hope is also implemented in other Southern
African countries. The programme will target all highly mobile
populations countrywide. Intervention activities will concentrate on
the treatment of STI's, condom promotion and prevention education.
One of the key focuses will be on safe sex practises through peer
education and outreach activities.
The overall HIV prevalence among pregnant women in
Botswana was 35.4% in 2002 as compared to 36.2% in 2001 and 38.5% in
2000. Generally prevalence in rural areas was higher than in urban
The CDC has collaborated with the Government of
Botswana, in developing educational materials, training counsellors
and provided technical assistance and support for the MTCT
A MTCT programme was the first program to distribute
antiretroviral drugs in Botswana, with the drug Zidovudine (AZT)
being provided free by the company GlaxoSmithKline. But the
enrolment of women in MTCT programmes has been disappointingly low,
in the range 11-20%. This low enrolment rate has been blamed on the
shortage of staff and on the need for improved infrastructure.
"We have very few and overstretched midwives. They
cannot reach all the pregnant mothers to do PMTCT counselling".
To rectify this many additional PMTCT counsellors
are now being trained.
The status of women in relation to men can create
further problems. Many women lack the power to control decisions
about sexuality and remain under the authority of their husbands,
parents and in-laws all their lives. There can also be further
difficulties when women return to their communities with formula
milk for their baby, as formula feeding can stigmatise and identify
the woman as HIV-positive.
"A wife needs a husband to test. She cannot do it
alone. We have to urge the communities to be supportive and rid
ourselves from stigma attached to a woman who feeds her baby on
It has been reported that the number of women
enrolling in PMTCT programmes in 2003 increased. It is hoped that
the wider availability of antiretroviral therapy for women and their
babies will now increase the numbers of women taking part of the
programmes even further.
You can find out more generally about HIV and mother
to child transmission here
Voluntary HIV counselling and testing (VCT) plays a
key part in HIV-related prevention and care. It is particularly
important as a starting point for the access of other
Since 2000, the government of Botswana and the CDC have supported
the Tebelopele network of VCT centres. The Tebelopele centres
provide immediate, quality, accessible and confidential VCT services
for sexually active Batswana aged 18-49. By October 2003, over
65,000 Batswana had used the Tebelopele centres.
The centres have been supported by the "Know Your
Status' campaign. The' Know Your Status' campaign is a part of the
VCT marketing strategy developed by the CDC in collaboration with
Population Services International (PSI). The campaign has also been
marketed through billboards, bus stops, banners, print
advertisements and regular radio programs throughout Botswana.
Also, ACHAP in partnership with the Botswana
Christian AIDS Intervention Programme (BOCAIP) is establishing
additional counselling and testing centres throughout Botswana. The
centres have reached over 70,000 attendants in their community
mobilization and outreach activities and the centres have trained
over 400 counsellors.
From the beginning of 2004, HIV tests are given as a
routine part of checkups in public and private clinics in Botswana.
The testing is part of the routine but people who do not want to be
tested can opt out. Botswana is the first country in Africa to have
a national policy of routinely offering HIV test, on a voluntary
Health Officials believe that routine testing is the
best way to rapidly improve the existing treatment programmes and to
decrease the burdens on hospitals by treating people with HIV or
AIDS at earlier stages and to give them a new prevention tool.
"Our single largest problem is the lack of knowledge
of HIV status...When you have that many people who don't know their
status, anything could happen. If each person infected another
person, they you could have 35 prevalence turn into 70 percent
prevalence. It's insane." -Ernest Darkoh
There is still a lot of stigma attached to sexually
transmitted diseases and people are afraid to get tested for HIV.
The government officials see routine testing as one way of removing
stigma by making testing routine.
In March 2001, President Festus Mogae announced that
the Botswana government would provide antiretroviral medication for
all those who needed it, before the year end. The government was
conducting a "needs assessment", and would pay a "substantial"
portion of the program's costs. It was hoped that the program would
be operational by the end of the year.
By January 2002 the aim was to provide medication
during 2002 for 19,000 of the 110,000 infected people who it was
considered could benefit from therapy. As a result of poor resources
- laboratory capacity, human resources and poor infrastructure, it
was decided to initially target certain population groups. These
included people suffering from TB, mothers, babies and their
spouses, as well as patients with a CD4 count of less than 200,
and/or AIDS defining illnesses.
The National Antiretroviral Therapy Programme was
given the name MASA, the Setswana world for 'new dawn', and the
first antiretroviral drugs were provided in Gaborone in January
2002. ACHAP is one of the partners in the program providing both
financial and technical assistance.
By the time of the start of MASA, there were already
warnings about the financial sustainability of the program. It was
estimated that the program would cost US$24.5 million in 2002 to
include 19,000 people, and then an additional 20,000 people would be
admitted each year.
"The programme is most likely not sustainable at
that level. Our hope is that over time, as the anti-AIDS messages
sink in , the rate of infections will fall and there will be a
smaller number of people needing the drugs", President Mogae was
reported as saying.
But as MASA started to enrol more people during the
year, so other problems became apparent.
"We are short of doctors. We are short of nurses. We
are short of pharmacists. We are short of health technicians." -
By June 2002, an estimated 1,000 people had been
enrolled. Of these, 500 were on therapy, whilst the remainder were
being assessed. Although the numbers were disappointingly small, the
indications were that few people were having difficulty adhering to
the complex antiretroviral regime. It had been a major concern that
the poorly educated people would struggle to understand the
importance of taking the complex cocktail of drugs on time and the
fact that the treatment is for rest of their life. To help to cope
with their adherence, NACA has come up with a support system. The
'buddy system' operates in such a way that each patient is
encouraged to form a special bond with someone close, who then makes
sure that the patient follows their medication schedule. The
patients in turn, counsel others who feel they may need help, to
By September 2002, the numbers had increased to
2,200 enrolled of whom 1,500 were on treatment.
It had become clear that enrolling people was a
lengthy process. It involved counselling at testing centres,
screening blood once a person knew their status, taking a white
blood cell count and then eventually enrolling in the programme. The
introduction of antiretroviral therapy had required the broadening
of the infrastructure including testing centres, storage facilities,
equipping existing clinics and hospitals and training medical
personnel. But the shortage of trained staff was acute and:
"We have realised that it takes time to train
doctors, nurse, laboratory and pharmacy technicians as we don't have
a medical facility."
"We need help... We are recruiting here and abroad.
We're getting 100 Cuban doctors. Even the Peace Corps are coming
back." -Dr Khan, head of NACA-
The slowness of enrolment was also adding to the
pressure on existing staff.
"The need for treatment far outstrips our ability to
deliver it. There is a lot of pressure on us, because if we fail,
people will say: Botswana had everything going for it and it failed,
so why should we help anyone else in Africa?" -Dr Moffat, Princess
Even if staff is available, there are delays with the formalities of
appointing new doctors.
By January 2003 there were about 3,200 people
enrolled on MASA and it was becoming clearer not only what had been
achieved but also how much more needed to be done.
"It's an impressive start to a programme that began
at ground zero and had to launch from there. When viewed from a
backdrop of what needs to be done however, it's not enough" -Ernest
Darkoh Operations Manager MASA-
"It's mind-blowing. We're achieving miracles, and
it's totally insufficient."-Donald de Korte -
It was estimated in May 2004, that more than 24,000
people had been enrolled on MASA, 14,000 of these people were
receiving antiretroviral treatment. The Princess Marina Hospital in
the capital Gaborone, is currently the largest single provider of
ARV therapy in Africa, with over 4,500 patients receiving
By the end of 2004, UNAIDS/WHO estimates showed that
between 36,000 and 39,000 people were receiving ARV treatment,
including those using the private sector. By March 2005, this total
had risen to 42,000 people, well over half of the 75,000 believed to
be in need.
As has already been mentioned above, there is an
acute shortage of health care workers in Botswana, and this is
having a significant affect on programs such as MASA. Many skilled
professionals have been hired away from the public health system
with offers of better pay and benefits, also some are leaving for
other countries. The problem is compounded by the fact that over 90%
of the doctors are foreign and do not speak Setswana, the local
language. Another problem faced when recruiting health care staff
from abroad is that it takes time for them to become familiar with
the local culture.
There are a number of initiatives taking place to
overcome this problem. To ease of the shortage of trained staff,
NACA is developing a system of lay counsellors to ease the workload
of some of the nurses. It has also been suggested that government
should recruit traditional healers as partners in the antiretroviral
program, for example, encouraging patients to enter the program and
take their drugs properly. The Botswana-Harvard AIDS Institute
Partnership has implemented a training program for health
professionals in Botswana. And the KITSO AIDS Training Program aims
to provide training in HIV and AIDS care including cultural aspects.
At the beginning of 2003 a series of HIV/AIDS
related educational videos were released. The Patient Education
videos are a collection of videos designed to educate people about
the impact of HIV/AIDS and antiretroviral therapy on their lives.
They include people from Botswana telling their story in their own
language. The videos focus on the importance of knowing your status,
the need to always use a condom when having sex, the hope that ARV
therapy offers and the responsibility to adhere to the therapy
regimen for the rest of person's life. The videos are being played
in patient waiting areas and are also being used in health education
talks in up to 120 hospitals and clinics. It has been reported that
patients in the MASA programme have 90% to 100% drug regimen
adherence rates (- as much as 20% higher than in most successful
programmes in Western countries.) This success has been attributed
to the intense counselling given to patients and the effectiveness
of the drugs.
In February 2004, Botswana received the first
instalment of P44 million from the US fund known as the President's
Emergency Plan for HIV/AIDS Relief. The funds will ensure
continuation of the BOTUSA collaboration between CDC and Botswana
government. New support under the first instalment include training
programmes, stigma reduction activities and assistance to Botswana
non-governmental organisations (NGOs) involved in the HIV/AIDS
Botswana has succeeded in a number of different
HIV/AIDS related interventions. The country has many different
HIV/AIDS education and prevention initiatives and strategies, and
prevention remains the cornerstone of the latest National HIV/AIDS
strategy. The Tebelopele VCT centres have been successful with more
than 60,000 people being tested so far. And the HIV incidence
amongst pregnant women has declined slightly in the last few years.
Botswana is a county that has aimed to provide
antiretroviral drugs to its HIV positive people. But its ambitious
antiretroviral drug programme, MASA, has not yet been as successful
as first hoped. Of the 300,000 HIV-infected people, 110,000 were
estimated to meet the criteria to qualify for treatment. The
government aimed to enrol 19,000 people in the first year, but only
3,500 were actually enrolled.
This disappointing outcome has highlighted a number
of issues related to providing antiretroviral therapy in Botswana.
These include the education and training of health care workers and
the strength of the infrastructure. If other countries with fewer
resources by head of population are to follow the example of
Botswana, there are still many lessons to be learned. A considerable
emphasis needs to be placed not only on the availability of
antiretroviral drugs, but the availability of health care
professionals and an adequate infrastructure.
If other countries are to succeed in implementing
antiretroviral drugs programmes, and if Botswana is to speed up its
program, then maybe more innovative approaches, such as the use of
considerably more lay staff, will be needed if sufficient progress
is to be made. Understandably, everybody wishes to have a really
good antiretroviral program, but maybe more consideration has to be
given to developing a "good enough" standard of treatment and care
if antiretroviral therapy is to save enough lives.
Whilst every effort has been made to increase the
provision of ARVs in Botswana, what is also important, is that
effective HIV/AIDS prevention continues.
"From the poorer African to the richest AIDS victim
in America, no amount of money can change the fact that the
antiretrovirals merely postpone, for unknown time period, the
inevitable victory of HIV/AIDS over the body it invades'." -Ernest