Download HIV/AIDS in Botswana

HIV/AIDS in Botswana
Botswana is among the countries hardest hit by AIDS. In 2003 there were an
estimated 350,000 people living with HIV. This, in a country with a total population
below two million, gives Botswana an adult HIV prevalence rate of 37.3%, the second
highest in the world after Swaziland.
Botswana was the first African country to aim to provide antiretroviral therapy (ARV)
to all its needy citizens. Many believe that if anywhere in Africa is going to succeed
in implementing such a comprehensive HIV/AIDS care and treatment programme,
then it is Botswana. This Southern African country has enjoyed unbroken peace since
gaining independence in 1966, and has become relatively prosperous thanks to its
diamond mines, though much of the population remains in extreme poverty.
Botswana's first AIDS case was reported in 1985. At that time 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 quite narrowly focused.
During the third stage (1997 onwards), the response to HIV/AIDS was expanded in
many different directions to include education, prevention and comprehensive care
including the provision of antiretroviral treatment, with the overall goal of not only
reducing HIV infection and transmission rates, but also reducing the impact of HIV
and AIDS at all levels of society.
The National AIDS Co-ordinating Agency (NACA) was formed in 1999 and given
responsibility for mobilising and coordinating a multi-sectoral national response to
HIV and AIDS. NACA works under the National AIDS Council, which is chaired by
the President and has representatives from 17 sectors including civil society, the
public sector and the private sector.
Early in 2001 the Government decided to initiate a rapid assessment of the feasibility
of providing antiretroviral drugs through the public sector. The treatment programme
began at a single site in January 2002, and after a slow start expanded rapidly during
2004, so that around half of those in need were receiving medication by the end of the
year.
Prevention programme
There are a number of different types of HIV prevention programme currently taking
place in Botswana. These include:
Public education & awareness
Public awareness and education has previously been based on the “ABC” of AIDS:
Abstain, Be faithful and, if you have sex, Condomise. One recent initiative has been
the development 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. HIV education has been taken to
people's doorsteps by the Total Community Mobilization programme.
Education for Young people
It is crucial that young people be provided with HIV education and prevention
messages to help protect them from infection. Among those performing this role in
Botswana is the Youth Health Organisation (YOHO), a youth-run non-governmental
organisation that conveys its messages through art festivals, dramas and group
discussions. School-based learning 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, to demystify and
destigmatise HIV/AIDS, and to break down cultural beliefs about sex and sexuality.
Condom distribution
Successful social marketing and subsidisation have substantially increased condom
use in Botswana. Population Services International (PSI) has helped to promote the
'Lovers Plus' condom since 1993 and the 'Care' female condom since 2002. One of
PSI's key strategies for marketing condoms has been peer education, which has been
conducted in a variety of settings such as fairs and festivals, shopping malls,
workplaces and bars.
In 2003 the Government of Botswana, with funding and technical support from
ACHAP, launched an extensive condom distribution and marketing campaign,
providing for the installation of 10,500 condom dispensers in traditional and nontraditional outlets throughout the country. Millions of condoms have been procured
for free distribution.
Targeting of highly mobile populations
Highly mobile populations, including migrant workers, are often especially likely to
be exposed to HIV. Therefore the Botswana Government, American Government
agencies, NACA, ACHAP and several other partners are initiating a prevention
programme linked to the Corridors of Hope project (which is also being implemented
in other Southern African countries).
The programme will target all highly mobile populations nationwide, concentrating
on the treatment of sexually transmitted infections, condom promotion and prevention
education. One key focus will be on encouraging safe sex practices through peer
education and outreach activities.
Improvement of blood safety
The Ministry of Health, the Safe Blood for Africa Foundation and other partners, with
funding from ACHAP and PEPFAR, have helped to improve the safety of blood
transfusions in Botswana. The national supply of HIV-free blood doubled in size in
the two years up to September 2005. Over the same period, the amount of HIVinfected blood given by donors fell by half, largely because of better screening of
donors and counselling.
One of the projects contributing to the improvement in blood safety is called "Pledge
25". This project recruits young people to become blood donors and teaches them
how to prevent HIV infection. The young people are encouraged to pledge to donate
blood 25 times during their lifetime.
Prevention of mother to child transmission of HIV (PMTCT)
In the absence of any interventions, around a third of the babies born to HIV-positive
mothers will become infected during pregnancy and delivery or through
breastfeeding. This rate can be cut substantially through the use of antiretroviral
treatment and safer feeding practices.
A prevention of mother-to-child transmission (PMTCT) programme was the first
programme to distribute antiretroviral drugs in Botswana, with the drug Zidovudine
(AZT) being provided free by the company GlaxoSmithKline. However, early
enrolment of women in PMTCT programmes was disappointingly low, in the range
11-20%, and this was blamed on a shortage of staff and inadequate infrastructure. The
Government responded with training and recruitment programmes for PMTCT
counsellors.
The status of women in relation to men creates 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. A woman who returns to her community
with formula milk for her baby risks being stigmatised, as formula feeding can
identify her as HIV-positive.
Recently, PMTCT efforts have expanded considerably, and services have been
established in all public facilities through the Maternal Child Health/Family Planning
system, which serves over 90% of all pregnant women.
HIV testing & 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 accessing other
HIV/AIDS-related services.
Since 2000, the Government of Botswana and the CDC (through BOTUSA) have
supported the Tebelopele network of VCT centres, which provide immediate,
confidential VCT services for sexually active Batswana aged 18-49. By October
2005, the network had expanded to sixteen centres and eight satellites, and had
provided free VCT services to over 230,000 visitors. Tebelopele became an
independent non-governmental organisation in 2004.
Routine testing
Since the beginning of 2004, HIV tests have been offered as a routine part of
checkups in public and private clinics in Botswana. The testing is part of the standard
routine but people who do not want to be tested can opt out.
Botswana was the first country in Africa to have a national policy of routinely
offering an HIV test at clinics. Health officials believe that routine testing is a good
way to help prevention programmes and to lessen the burden on hospitals by helping
people to access treatment at an earlier stage of disease. There is still a lot of stigma
attached to sexually transmitted diseases in Botswana. Officials believe this stigma
can be reduced by treating the HIV test just like any other routine medical procedure.
In the first six months of 2005, some 74,134 people were tested via the routine testing
programme.
HIV/AIDS treatment
In August 2000, President Festus Mogae said that new funding from ACHAP would
allow his country to provide antiretroviral therapy to all HIV-infected pregnant
women and children born with the virus. In March 2001, the President announced his
Government hoped to implement a national treatment programme before the end of
the year. The Government was conducting a needs assessment, and would pay a
"substantial" portion of the programme's costs.
The expected benefits were fourfold:
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To enable people with HIV to live longer, healthier lives
To offer an incentive for HIV testing, and to lower the rate of HIV
transmission
To decrease the number of children orphaned each year by AIDS
To maintain skills in the workforce necessary for economic development
This was the first time any African country had proposed such an ambitious
programme, and some doubted whether it was really feasible.
By January 2002, the aim was to provide medication during the coming year to
19,000 of the 110,000 infected people whom it was considered could benefit. As a
result of poor resources - laboratory capacity, staff and infrastructure - it was decided
to initially target four population groups: pregnant women with AIDS, HIV-positive
child in-patients, HIV-positive people with TB, and adult in-patients with AIDS.
The national antiretroviral therapy programme was given the name MASA, the
Setswana word for "dawn", and the first antiretroviral drugs were provided at the
Princess Marina Hospital in Gaborone in January 2002.
By June 2002, an estimated 1,000 people had been enrolled in MASA. Of these, 500
were on therapy, while the remainder were having their requirements assessed.
Although the numbers were disappointingly small, the indications were that few
people were having difficulty adhering to the antiretroviral regime. There had been a
major concern that poorly educated people would struggle to understand the
importance of taking the complex cocktail of drugs on time for the rest of their lives.
The introduction of antiretroviral therapy had required broadening the infrastructure
including testing centres and storage facilities, equipping existing clinics and hospitals
and training medical personnel. The shortage of staff was the single biggest
constraint on treatment scale-up. Many skilled professionals had been lured away
from Botswana's public health system by offers of better pay and benefits, and some
had moved abroad. To compensate, Botswana recruited workers from poorer parts of
Africa, as well as from India and Cuba. As a result, most of the doctors were foreign
and did not speak the national Setswana language.
When each new site opened, many of the first patients to enrol were already very sick,
and so required a lot more time and resources. HIV-related stigma and denial was
also a major barrier to people accessing services. As 2003 drew to a close, MASA
was still a long way short of the 19,000 target originally set for the end of 2002, and
some observers argued the programme had been mismanaged, and was not a good
example for other African countries to follow.
By September 2005, 54,378 people were receiving treatment. 4,582 children were
receiving treatment through MASA by the same date. A study published in
November 2005 found that the first patients to receive treatment through MASA
experienced "excellent" responses, comparable with those seen in the developed
world. However drug toxicity was a significant problem, and led to changes in the
drug regimen.
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Routine testing has increased demand for treatment, especially among people
without symptoms.
A social mobilisation campaign has raised awareness of the availability and
effectiveness of antiretroviral treatment, and has helped to reduce stigma and
discrimination. Once people see for themselves how therapy has benefited
others, they become more eager to seek services.
The programme has been well supported. As of mid-2005, Government
expenditure on treatment scale-up was expected to be around $62.1 million in
2004-5. An additional $3.3 million was expected from the Global Fund, $6.4
million from PEPFAR and $20 million from non-governmental organisations,
charities and foundations.
Botswana has more money, better infrastructure and a better health system
than most other sub-Saharan African countries.
The Princess Marina Hospital in the capital Gaborone was the largest single
provider of antiretroviral therapy in Africa, and 31 other sites in Botswana
were offering free treatment, including at least one in each of the 24 health
districts. About three quarters of those receiving treatment are doing so
through the public sector, but an increasing number of private companies were
also offering treatment to their employees
Botswana's national treatment programme is now seen as a successful model for other
African countries to follow. Though progress was initially slower than expected, the
programme made rapid progress in 2004 and 2005, and patient responses have been
comparable to those seen in Europe and the USA.
MASA has demonstrated that antiretroviral treatment can be provided on a national
scale through the public health system of a sub-Saharan African country - not just
through localised projects run by foreign aid workers or researchers. In Botswana's
case, almost all of the actual cost of treatment has been paid by the Government,
while other partners have given support by providing laboratory equipment, staff
training or patient monitoring services.
But the struggle to provide universal treatment in Botswana is far from over. In the
first place, there are still thousands of people dying because they are not receiving the
medicines. In addition, all of those already enrolled must continue to receive drugs
and monitoring services for the rest of their lives, and people who develop resistance
to their current medications must have access to alternatives, which can be more
expensive and complex than first-line therapy.
It is much easier to provide treatment in towns than in rural areas, and MASA will
need to be rapidly decentralised to ensure that all districts are covered. The shortage
of skilled staff will continue to be a great challenge to MASA, and the programme
will continue to be very expensive. The need for help from the rest of the world is as
urgent as ever.
Even if universal access is eventually achieved, antiretroviral treatment alone cannot
solve Botswana's devastating HIV and AIDS crisis. Botswana's long-term vision is to
have no new HIV infections by 2016, when the nation will celebrate 50 years of
independence. This will never be achieved without a massive and sustained HIV
prevention campaign.