Unprecedented political will, adept management and innovative partnerships have so far helped Botswana effectively confront its greatest challenge — HIV and AIDS; and, according to reports from the recent Botswana International HIV Conference (held from September 13-16, 2006 in Gaborone, Botswana), the country is meeting many of the targets it has set for itself fighting the disease, in the areas of HIV testing, the rollout of antiretroviral treatment (ART), the prevention of mother to child transmission (PMTCT), and, according to recent surveillance data, in reducing HIV prevalence.
However, the country still faces serious challenges. “We have made some progress but we are not yet out of the woods,” President Festus Mogae said at the Conference opening in Gaborone. “HIV’s persistence continues to severely compromise the health status of our nation. More than any other factor, it threatens to undermine our past gains and future potential as a developing society.”
For example, HIV prevalence is still quite high, public knowledge about HIV incomplete and sexual attitudes and behaviours have been stubbornly resistant to change. Some programmes, such as the infant formula feeding programme, are not operating as smoothly as everyone would like to think. Furthermore, there are indications that the pace of the rollout could even be slowing as the country is reaching the limits of its existing healthcare capacity.
Botswana backgrounder
Botswana is a sparsely populated southern African country about the size of France or Texas. The country achieved independence from the UK on September 30, 1966 and has been a stable democracy ever since. Most Batswana were pastoralists (many still are), and after years of colonial neglect, the country was undeveloped. However, shortly after independence, rich mineral deposits were discovered in the eastern part of the country that dramatically expanded the domestic economy. Then in the 70’s and 80’s, three of the world’s biggest diamond mines were opened in Botswana.
Contrary to popular belief, this has not made many Batswana wealthy — relatively few Batswana actually work in the diamond mines and much of the profit has been reaped by De Beers. However, the government wisely recycled its share of the diamond revenues into domestic public programmes. Botswana belatedly began to build an infrastructure, including one of the best primary healthcare systems in Africa.
Partly because of the diamond revenue, Botswana is now considered a “middle-income” country but this perception of Botswana’s wealth may be somewhat misleading to anyone who has never been there.
For example, the differences remain startling between the development in the east (as evidenced by the prosperous Gaborone) and the relative lack of infrastructure in many remote villages in the centre or west of the country (where there are few paved roads, little electricity or refrigeration, and less “access” to piped water). In the rural settings, people are still probably better off than in many parts of Africa — they are better nourished, and their small grass, stick or mud homes are well maintained. Villages may even have a communal vehicle to transport goods or people into neighbouring towns an hour or two away, and families are able to send their children away to neighbouring towns for schooling. Even so, most people in the more remote areas areas don’t have much.
The majority of Botswana’s 1.7 million citizens live in the more urbanised eastern third of the nation — at least part of the year. Here many homes have indoor plumbing or at least access to piped water somewhere in the village.
Although these urban centres have more infrastructure, conditions in some of the peri-urban communities surrounding the mining towns, such as Selebi-Pikwe, remain poor and overcrowded.
The Batswana are very mobile. Moving between the rural and urban areas is common and people keep close ties to their family village regardless of where they work. Social laws in Botswana are conservative with anti-sodomy laws and laws that forbid divorce for any reason within the first two years of marriage. The latter law may serve as a disincentive to marry, however, as only 11% of the pregnant women participating in the 2005 sentinel survey were married. Multiple concurrent partnerships (with perhaps a wife in the home village and a steady girlfriend in the town) are common, as is intergenerational sex.
The HIV epidemic in Botswana
It was in this environment that, in the late 80’s and early 90’s, HIV-1 subtype C quietly entered into the population and rapidly took hold before anyone anticipated the scale of the problem.
Early projections of the impact of the HIV upon population were particularly dire. It was estimated that by 2010, out of a total population of 2.4 million people, 1.78 million would be infected with HIV.
Fortunately this prediction was substantially off at least partly because of the interventions that the government has put into place. Even so, by 2003, an estimated 350,000 Batswana were HIV-infected, with over 33,000 deaths from HIV/AIDS-related causes that year.
As of the most recent sentinel surveillance report, 33.4% of women attending antenatal clinics were HIV-positive, and an estimated 17.1% of the general population is HIV-infected. These figures are a bit lower than were reported a couple of years ago, though it may be premature to declare this to be a trend (see below). The estimated number of adults aged 15-49 living with HIV is over 256,000 (158,000 women, 98,000 men) but by definition the figure does not include the cumulative number of children and older adults who are now infected.
“It’s a small population and everybody is precious,” said Professor Sheila Tlou, a professor of nursing and an activist around issues of gender and development who is now the Minister of Health in Botswana. “However, we were threatened by HIV/Aids and became one of the highest prevalences in the world.”
Afraid that HIV/AIDS could lead to the very extinction of his people, President Festus Mogae and his government established HIV/AIDS as the government’s highest priority. The President issued a formal declaration of war on HIV/AIDS, established the National AIDS Council and began to mobilise the first and most comprehensive anti-HIV programme in Africa.
The government has committed substantial resources (beyond the 15% of GDP targets to fight HIV set by African governments in the recent Abuja declaration). It sought assistance from foreign experts, and formed strategic partnerships with such as the Botswana Harvard AIDS programme (which among other things, helped develop the KITSO programme to train healthcare workers), the African Comprehensive HIV Programme (partnering with the Bill and Melinda Gates Foundation and Merck), BOTUSA (a partnership with the US Centres for Disease Control), Baylor Children’s Hospital, and more recently PEPFAR.
In 2001, the government commissioned a baseline consultancy report from McKinsey Global Institute to help determine the need for ART and comprehensive care within the country. At the time, it was estimated that 110,000 persons would need ART in Botswana (including 48,000 males, 55,000 females and 7,000 children). A couple of years later, WHO projected that the country had 84,000 people immediately in need of treatment (using WHO guidelines for treatment eligibility).
Of course, scale-up takes time, and operational managers for MASA (Botswana’s ART programme) are fond of saying that the rollout follows a sigmoid pattern (small numbers of patients at first, but with rapid expansion after a site comes fully on line). They made following projections for patient enrollment into MASA:
December 2006 – 60,000
December 2007 – 80,000
December 2008 – 100,000
December 2009 – 150,000
Some positive results
As of June 2006, Botswana already had 68,440 people on ART, including 56,162 in the public sector, 3778 outsourced to private practitioners (but government funded), and 8500 through privately funded insurance/medical aid schemes. Depending on whose figures are used (WHO’s or McKinsey’s), Botswana has put between 70-85% of its eligible citizens with HIV on antiretroviral therapy (ART) — leading to a reduction in mortality as well as improvement in the quality of life for people living with AIDS. In fact, the country is one of few in Africa to have met WHO 3x5 initiative targets
It was quickly realised that voluntary counselling and testing was a bottleneck to enrolment in MASA. People simply weren’t coming in for testing and were not diagnosed for HIV until their disease was already very advanced — at which point, they were more likely to die or fail on therapy. In response, the country established a programme of routine opt-out testing, which foregoes pre-test counselling but is supposed to give people a choice to say no.
In practice, the programme has not been without problems including complaints of testing without knowledge or informed consent. But since its introduction in January 2004, routine testing has dramatically increased the number of people in Botswana who are now aware of their status — and many in immediate need of treatment has been referred to the MASA programme.
“Our routine HIV testing strategy is now widely acknowledged to have been a success, not respective of the continued reservations of a few critics. Through this initiative, some 300,000 [persons] have been tested,” said President Mogae.
One of the first programmes to get off the ground was PMTCT. Now over 90% of the pregnant HIV-positive women in Botswana and their infants reportedly receive antiretroviral prophylaxis for the prevention of mother-to-child-transmission (PMTCT). At least in one evaluation in Francistown, the programme is also highly effective, reducing MTCT to just 7%. However, it may be premature for the government to make claims that the programme is equally successful nation wide.
As already noted, recent sentinel surveillance data suggest that the HIV prevalence could now be falling in the country.
Not time for ululating, yet
“But it is not yet time for us to start ululating. We are definitely seeing declines, especially among young people but we’ll see how far those declines go,” said Minister Tloe.
Indeed, it is quite possible that infection may simply be delayed in younger women — a significant concern as data from the BAIS II study in 2004 suggests that only 23.9% of the women aged 15-19 and only 30.4% of the women between the ages of 20-24% are aware that having multiple partners puts them at increased risk of infection.
And despite surpassing the 2006 goals for ART, there are also indications that the country could now be reaching the inherent limits of the existing healthcare capacity (both in human resources and material infrastructure) as well as the limits of its hospital based delivery model — thus slowing the pace of the rollout.
MASA started out with four sites in key urban settings across the country: Gaborone, Francistown, Maun and Serowe. From there, MASA expanded to the district level hospitals (there are currently 24 health districts in Botswana). Presently, there are 32 full-fledged ART sites.
According to Dr. Ndwapi Ndwapi, Operations Manager of MASA, after the emergency scale-up, many ART sites are suffering from “cumulative infrastructure overload with well patients. And what we mean by this is that by the time you are treating 150,000 patients, most of those patients are healthy and they are required to come every month to the hospital system in pursuit of care. And to have your healthcare system clogged with 120,000 well people, may not be what the healthcare system was designed to do.”
To relieve congestion at the country’s primary ART sites, the programme has been relying more on district level hospitals and plans to move onto their satellite clinics. Dr. Ndwapi says that, by scaling up at these clinics, there is a potential for an additional 128 free-standing treatment centres by 2010.”
But, according to aidsmap.com sources, many of the district level hospitals have already reached capacity and plans to further decentralise care to the clinic and primary healthcare level have, so far, been thwarted by logistical problems. And even should some of those clinics go online, they won’t be able to handle the same numbers of patients managed at the larger hospitals. In the meantime, some of the hospitals are expanding (with substantial sums being spent on construction) — but it is not clear who will staff them.
It is important to remember that the number of people in immediate need isn’t static — it grows as people with HIV experience disease progression. According to Dr. Boga Fidzani, the Monitoring and Evaluation Advisor for National Aids Coordination Agency, it isn’t clear how many people will be needing treatment in the next couple of years: “There’s an urgent need to update estimates on the number of people in need of treatment. The last estimates were actually done in 2001 and we think it is time to come up with fresh estimates.”
“With an increasing number of HIV infected persons now seeking treatment, the capacity we build in terms of human and material infrastructure remains a priority,” said President Mogae.
To expand beyond these limits, and maintain the progress it has already made, the country may need to re-examine some of its policies and protocols, as well as explore new healthcare delivery strategies.
“We shall need to try fresh approaches to try and sustain initiatives that we have already put in place,” said President Mogae.
Proud Batswana like to say that “they will make a way.” How creatively and expeditiously Botswana deals with these challenges will decide whether the nation’s fight against HIV will, in the end, be a victory; while how open the Batswana are about their successes and failures will determine how much they have to teach others in the region.
Over the next week, aidsmap.com plans on examining some of Botswana’s triumphs and ongoing challenges in a series of articles with material drawn from the World AIDS conference in Toronto, the conference in Gaborone, as well as clinic visits and interviews conducted in Botswana since that meeting.