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AIDS in Africa - Botswana

 

 

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.

The History of HIV/AIDS in Botswana

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 Council.

What is happening now?

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 antiretroviral drugs.

HIV/AIDS prevention

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 Education & Awareness

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.

Education for Young People

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.

Condom distribution and education

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% for men.

Targeting of Highly Mobile Populations

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.

Prevention of mother to child transmission of HIV (PMTCT)

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 areas.

The CDC has collaborated with the Government of Botswana, in developing educational materials, training counsellors and provided technical assistance and support for the MTCT programmes.

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 formula".

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

HIV and AIDS treatment and care

Voluntary testing and counselling

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 HIV/AIDS-related services.

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 basis.

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.

Antiretroviral therapy programme MASA

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." - President Mogae-

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 come forward.

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 Marina clinic-
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 antiretrovirals.

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.

Education and training of health care workers

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.

Antiretroviral support and education

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.

Support from the US emergency plan

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 effort.

The Way Forward

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 Darkoh-