Many problems including the stigma that surrounds HIV/AIDS have resulted in Botswana having one of the highest infection levels in the world.

(Article taken from the African Investor: The Botswana Issue, June 2004)

Botswana has the highest level of HIV infection, measured at antenatal clinics, anywhere in the world. Although the rate dropped slightly from 38.5% in 2000, to 36.2% in 2001, and 35.4% in 2002, President Festus Mogae acknowledged that the seeming improvement is at least partly attributable to the rising death rate of a maturing epidemic.

Despite this, Botswana is seen as a hopeful case. Mogae has been at the forefront of his country's fight against the disease. Unlike the denial which paralysed much ofAfrica's leadership, Mogae realised, as he told the UN General Assembly in 2001, that the epidemic was "a crisis of the first magnitude". Botswana, he said, "was threatened with extinction".

The National AIDS Co-ordinating Agency, set up in 2000, is chaired by the President and, as with Uganda's President Yoweri Museveni, the fight against AIDS has become Mogae's personal crusade. At a one-day conference on 'Botswana's strategy to combat AIDS', held in Washington on 12th November 2003, US officials praised Mogae for his "clear and candid" vision, and for tackling the problem "effectively and honestly". US Senator Norm Coleman (Minnesota) praised Mogae, too, for publicly taking an HIV test, to demonstrate to his people that no-one must believe he or she is immune to HIV/AIDS. The US, in turn, was committed to helping Botswana financially and in providing human capacity to deal with the epidemic. A major initiative, the African Comprehensive HIV/AIDS Partnerships (ACHAP), is a collaborative public/private partnership between Botswana's government, the pharmaceutical company, The Merck Company Foundation, and the Bill and Melinda Gates Foundation. The foundations have both pledged $50 million in assistance over five years. Merck is also offering two ARV drugs at no cost. In another initiative, the Harvard AIDS Institute has developed a training programme for the country's healthcare workers, and opened a research laboratory in the capital, Gaborone. In June 2003, a $9.7 million centre for AIDS-afflicted children, funded by Bristol-Myers Squibb and the Baylor College of Medicine in Texas, opened in Gaborone.

Denial getting in the way of behavioural change

And yet, despite strong leadership, generous funding, and even some free drugs, the AIDS programme is struggling. The ACHAP goal of no new infections by 2016 seems impossibly difficult to attain. Despite very high profile safer-sex education initiatives, AIDS workers complain that behaviour has not changed. In his state of the nation address in November 2003, Mogae said: "We have spoken of the HIV/AIDS pandemic as a war that needs to be won. Yet in this war we remain our worst enemy: it is we alone, who through behaviour change, must achieve our victory."

Despite the ravages of the disease around them, probably 90% of the population do not know their HIV status. The disease is surrounded by denial. At funerals where there are routinely mentions of cause of death, the family will speak of tuberculosis, or the anger of ancestors. Suzette Heald of Brunel University in London, who did research on social perceptions of the disease in Botswana, found that the views of government health education programmes, those of traditional healers, and of the separatist churches, with their prophet healers, were often in conflict. While the government programmes take a conventional Western biomedical, 'neutral' view of the disease, traditional healers might see AIDS as a 'new' version of 'old' Tswana diseases, brought on by breaking taboos, or linked to witchcraft; the prophet healers might see AIDS as a punishment sent by God for unnatural or sinful acts. Some of Heald's informants believed that the disease had been deliberately introduced by whites with genocidal intent. Bombarded with such conflicting theories, it is easy to see not only how the 'neutral' health message can be undermined, but how denial and stigmatization of the disease are reinforced.

Routine testing now available at health facilities.

Late last year, the Boston Globe reported President Mogae as saying: "I'm very frustrated. We think because of the stigma attached to this sexually transmitted virus, and because some of our religious people have said this is a curse or those who have it are sinners, that people are afraid to get tested. One way of removing the stigma is making testing of HIV a routine thing."

A decision has since been made by President Mogae that all patients visiting health facilities should be routinely tested for HIV, unless they object. Although this strategy will undoubtedly meet with resistance from the human rights activists, he believes that unless the infected know their status they will not enroll for Botswana's free antiretroviral treatment programmes until it is too late - one factor that has meant the programmes have not grown as quickly as anticipated.

Of the 110,000 estimated to need ARVs, far less than the 19,000 it was believed would access treatment by the end of 2002 are receiving treatment, and it was hoped that an additional 20,000 would be admitted to treatment each year.

Not knowing one's HIV status, and the stigma that persists around the disease, partly explain why patients wait until they are very ill and require hospitalization before going on to ARVs. As a result, plans to treat HIV/AIDS with ARVs on an outpatient basis, involving four or five visits a year, must instead anticipate seeing patients a few times a month, sometimes needing hospitalisation. Staff and facilities remain overstretched - something earlier recourse to ARV treatment could have alleviated.

Scarcity of personnel and infrastructure is a major constraint on Botswana's ARV programme. Even mother-to-child-transmission prevention is hampered by a shortage of midwives to counsel pregnant women. As a result only between 11% and 20% of women were enrolled in these programmes in 2002, although Mogae says that the figure has improved substantially recently.

Botswana does not have a medical school; 95% of its doctors are foreigners. To add to its woes, Botswana, like South Africa, loses its trained medical personnel to richer countries that can offer higher salaries and better working conditions.

The problem is compounded by an internal 'brain drain'. Mogae told the Washington conference that the shortage of doctors, nurses, pharmacists and other health workers was in part due to the way in which international organizations and NGOs, which come to help Botswana, raid the country's scarce professional resources. Offered better pay and benefits, they leave the public health system, forcing Botswana to recruit outside from India and Cuba, but also from other African countries. "If they let us steal them, we will," he said, "because our problem is worse."

Effective ARV treatment also requires a massive upgrade of infrastructure - not just clinic buildings and laboratories, but systems, preferably computerised, to track patients and keep medical staff in touch with information sources, and secure drug warehouses and distribution systems. Slow delivery on this front has also impeded the expansion of ARV programmes.

'Learn as we go policy' gets the ball rolling

In an article in the Financial Mail on 4th July 2003, Dr. Donald de Korte, project leader of ACHAP, and Dr. Ernest Darkoh, operations manager for ARV therapy in Botswana's ministry of health, set out some of the lessons Botswana had learned since starting its ARV programme in January 2001.

While the problems are 'daunting', they believe countries should not wait until all the components are in place before starting such a programme; they had "agreed upfront that we would 'learn as we go' because the goal was to save lives". They found, too, that "strong political will from the highest level of government, in conjunction with public-private partnerships such as ACHAP, is essential."

Interwoven with this should be other systems such as "leaner community-based models" which can ensure successful and sustainable service delivery.

At a World AIDS Day gathering in Gaborone, UNAIDS's director Peter Piot warned that Botswana's prevention efforts need to be "scaled up dramatically if we want to keep future generations AIDS-free".

Botswana's infection levels show no real sign of declining, and prevention is undoubtedly the first prize in the war on AIDS. Providing ARVs cannot be seen as a substitute for this, but it can alleviate the impact on those already infected. As Mogae points out, this cannot happen unless they come forward for testing - if they do not, he says, "we have only ourselves to blame for our suffering"

Source:

Omega Investment Research. “HIV/AIDS: Lessons from Botswana.”Africa Investor: The Botswana Issue. June 2004. www.omegainvest.co.za

Botswana in Brief:

The population of Botswana is around 1.6m, giving the country an overall population density of 2.7 persons per sq km (7.1 per sq mi). The majority of the population is concentrated in the eastern part of the country, and 50 percent live in rural areas. Many live in small villages surrounded by agricultural land.

The population growth rate in 2002 was 0.2 percent annually. Gaborone, the main business center, has a population (1999) of 202,680. Other business centers are Francistown (97,050), Selebi-Pikwe (47,868), Molepolole (45,811), Kanye (36,189), and Serowe (30,706).

Botswana received its name from the country's principal ethnic group, the Tswana. Representatives of several other peoples are also found, including a small number of San (Bushmen), who have inhabited the region for many centuries.

About one-half of the population practice traditional African religions; most of the remainder are Christians. English is the official language, but most of the people speak Setswana, the language of the Tswana, which belongs to the Sotho subgroup of Bantu languages.

In 2001 Botswana's adult literacy rate neared 88.6 percent. Most primary schools are supervised by the district councils and township authorities and are financed from local government revenues assisted by grants-in-aid from the central government.

Virtually all primary school-aged children were enrolled in school in 1998, while 77 percent of secondary schoolaged children were enrolled. Specialized education was provided by teacher training schools and vocational training schools.