Botswana Battles Against ‘Extinction’

Article By Liz McGregor in Gaborone for The Guardian

If there is anywhere in the world where a model for the treatment of HIV and Aids is needed, it is Botswana. This landlocked country in southern Africa has the highest incidence of the condition, almost 40% of its adult population being infected. The average life expectancy has just fallen below 40 years for the first time since 1950.
The desperate statistics require a radical response. Yesterday, as 15,000 delegates gathered in Barcelona for the 14th International Aids Conference, Joy Phumaphi, the Botswanan health minister, said: “We are all engaged in a fight to the death.”

Botswana has become the first African country to offer free anti-retroviral drugs to everyone who needs them: a comprehensive prevention and treatment campaign that could become a model for fighting the Aids epidemic throughout Africa. But the pressure is intense: if the campaign fails in this well-governed, relatively wealthy country there is little hope for its less fortunate neighbours.

The strain prevalent here is subtype C. The developed world has subtype B and east Africa mostly A and B. But it is subtype C, the most virulent and prone to resistance, that is threatening to explode in China and India. So far, 51 different strains of subtype C have been identified in Botswana alone.

One of the risks of a widespread distribution of the complex regimen of anti-Aids drugs to a population with a rudimentary healthcare system is that if the drugs are not taken properly increasingly resistant strains of the virus will develop that will make the current drugs ineffective. But Botswana is determined that it will be made to work.

This huge country, two thirds of which is covered by the Kalahari desert, is a model of good governance. Diamonds were discovered shortly after Britain gave it independence in 1966 and, unlike in neighbouring Angola, they have been used for its citizens’ benefit, including universal free education and health care.

It helps that the population is only 1.6m. But the epidemic is wiping out the workforce and eating up the national income. “We are faced with extinction,” says Dr Banu Khan, head of the National Aids Coordinating Agency, which was set up to implement the government scheme.

Festus Mogae, Botswana’s Oxford-educated president, has called for an all-out war on Aids and has appealed to the international community for help. Bill Gates has responded with a grant of $50m over the next five years, matched by another $50m from the American pharmaceutical company Merck. The Harvard Aids Institute is combining the donation of expert medical help with research into subtype C, including mother-to-child transmission and vaccine development.

In January this year Harvard helped set up Botswana’s first anti-retroviral (ARV) clinic, located at the Princess Marina hospital in Gaborone, the capital. To date, 885 patients have been treated.

A second clinic is just getting off the ground in Francistown, Botswana’s second city, with the help of a doctor and a nurse from Chelsea and Westminster hospital, London, but it seems unlikely that the government’s stated target – 19,000 patients on ARVs by the end of the year – will be met.

The Princess Marina clinic doctors are studying how communities adjust to people taking the drugs, and whether ways can be found to ensure they keep taking them. Only patients with either an Aids-defining illness such as TB,Karposi’s Sarcoma or chronic diarrhoea, or with a CD4 cell count lower than 200, are put on ARVs. CD4 cells, also known as T cells, are the immune cells attacked by the virus. Crucially, potential patients also need to demonstrate a commitment to treatment.

Botswana is drawing on the strength of its extended family system and insisting that patients bring along a relative or friend who will take responsibility for ensuring the patient takes the drugs as prescribed. The first stop for potential patients is an “adherence counsellor” and social worker who assesses whether they are likely to stick to the treatment.

Understanding and incorporating cultural factors is crucial to the success of the campaign. And fertility is important in this patriarchal, rural country.

“Women don’t work, especially at grassroots level,” says Patricia Bakwinya, who runs the Tshireletso Aids Awareness Centre in Francistown. “The man provides and he has girlfriends elsewhere. The woman can’t object because she needs the income. She keeps having children because that is the way to keep her man. But now women are realising that if they try to keep their man by having babies, they will die and their children will die.”

One positive spinoff of the epidemic is that more women seek paid employment. “They want to be self-supporting because it will help them stand up for themselves,” Ms Bakwinya says.

She began an Aids awareness group in her home three years ago because her friends were dying and leaving children in the care of bewildered grandmothers who could not cope. It has expanded into a daycare centre which provides free pre-primary education for orphans and after-care, counselling and meals for older children. It is a model that has been repeated through the country.

Despite the fact that there are 65,000 orphans in Botswana, the government is trying to avoid institutional care. Orphans receive financial help from the state, and there is home-based care for sick people. Voluntary testing centres and “coping centres” for those living with Aids are to be found in every town.

Mr Mogae mentions HIV in nearly every speech he makes. Yet progress against stigma and denial is slow. Only 12 of the 278,000 people thought to be living with HIV have gone public. The HIV incidence among girls aged 15 to 19 is 28% in some areas, twice that of boys of the same age.
This represents the newest infections, and is worrying in its implications for the country’s future economic and reproductive capacity, and because it shows that education is not particularly effective. The high incidence among girls reflects what is known as “inter-generational sex”: older men sleep with girls because they think they are less likely to be infected.

But the greatest threat is the shortage of skilled personnel to carry out the ARV programme beyond the specialised confines of the Princess Marina.

“The bottom line is: we need help,” Dr Khan says. ” The epidemic has put additional demands on us but is at the same time draining us of skilled people. We are recruiting here and abroad. We’re getting 100 Cuban doctors. Even the Peace Corps are coming back.”

At present the Botswana government meets 80% of the drugs bill. Most drugs firms are supplying drugs at cost price and Merck is giving them free.

Dr Donald de Korte, the former head of Merck in South Africa, runs Achap, a joint venture of the Gates and Merck foundations and the Botswanan government,in Gaborone. He says Merck’s culture of corporate responsibility is behind its actions: “But if you’re looking for a self-interested motive, it is that if this model works, it will be repeated throughout Africa and increase the pharmaceuticals’ markets.”

To Dr De Korte, the big question is the impact of treatment on prevention. “Suddenly HIV is not a death sentence and that changes everything.”

Dr Howard Moffat, the superintendent of the Princess Marina, says: “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?”