One of the key issues facing country programmes considering the introduction of antiretroviral therapy is the potential size of the commitment. Unless there is some prospect of success in prevention activities, patient numbers will grow indefinitely. Participants at the conference devoted much discussion to the reasons why Botswana has been so severely affected, and what can be done to improve prevention efforts.
Ten or fifteen years ago in southern Africa, hardly anyone was worried about HIV. Although, the first cases of AIDS were diagnosed in 1982 in South Africa and in Botswana in 1985, the disease spread very slowly in the 1980s. In fact, most people in the region thought AIDS was a white man's disease, an effect of malnutrition, or even worse, a fiction. To a surprising extent, these perceptions still persist in many areas.
What is shocking is how swiftly and deeply HIV got its hooks into the population during the last ten years - in many areas 30-40% of the population has been infected, and the majority of people in some age brackets. Similar data were reported at this month's meeting by the Local Government Minister, T Shipinare, from the most recent Botswana HIV/AIDS Surveillance report.
275,000 adult (15-49 years) Batswana are now estimated to be living with HIV/AIDS (out of a total population of ~1.6 million). 37.4% of adult pregnant women are HIV-positive, tens of thousands of their children become infected and even more will become orphans.
Some areas are particularly hard hit. In the mining district Selebi /Phikwe, the prevalence runs as high as 52.2%, probably the highest level anywhere in the world. However, Botswana no longer has the world's highest seroprevalence - that dubious distinction likely belongs to either Lesotho or Swaziland.
According to the Surveillance report, "condom use in the last sexual act with a non-marital and non-cohabiting partner was over 60%." Cultural practices which encourage intergenerational and multiple partner sex also persist, according to the survey. "The proportion of people with multiple partners is still high at 32% for men and 17% for women."
A number of sessions were devoted to reports on the attempts to reduce transmission through standard interventions such as PMTCT, screening and treatment for sexually transmitted infections and voluntary counselling and testing. Male circumcision and calls to ban or limit access to alcohol were also proposed as desirable interventions. There were also pleas to practice monogamy or abstinence rather than rely on the distribution of condoms, which some religious leaders present insisted was like "providing our youth with a license to fornicate."
In a plenary session on Africa's response to AIDS, United Nations Special Envoy for AIDS, Ambassador Stephen Lewis blamed such religious leaders for Africa's inadequate response to AIDS. "The religious leadership has been equally delinquent. The religious leadership say that they carry the moral flame, but it doesn't seem to be burning very bright and in some instances has been totally extinguished, as with the Catholic church's stance on condom use."
But above all, Lewis stressed, "gender lies at the heart of the pandemic. You are not going to beat this epidemic until you tackle the massive gender inequality that exists on this continent. It's going totake generations, but you have to empower women today."
Several presentations highlighted the woman's unequal role in Botswana. They all added to evidence that has been highlighted for years, but evidence nevertheless worth restating: women often have little control over sex. If they refuse sex from their partner, he could interpret it as a sign of unfaithfulness, and the partner could then rape her. These patterns are not merely applied to marriages but in affairs, dating couples and intergenerational relationships as well.
The woman has no right to refuse sex, and therefore winds up being put repeatedly at risk, and yet, if she tests positive she is condemned as adulterous or a prostitute. Fear of the male partner's reaction if he found out that she was positive came up again and again in Botswana as a reason for women not to get tested, to not return for test results, to not disclose her results, to not go into PMTCT studies, and not to go onto treatment. If they did get treatment, they might be poorly adherent because they would try to conceal pill taking.
It is this fundamental feature of African society, argue some that is at the root of the slow uptake of treatment in Botswana. This feature is not unique to Botswana, and will need to be addressed in all nations where treatment access is planned. When we talk about stigma as an obstacle to treatment scale-up, we are talking about a phenomenon that is largely structured by gender.