Scaling up antiretroviral therapy: learning from Botswana

The country with the world’s highest rate of HIV is now Botswana, in the heart of Southern Africa. Out of a total population of 1.6 million people – in a country the size of France – 330,000 are now HIV positive. Of those, around 110,000 are in immediate need of antiretroviral treatment according to the World Health Organisation’s recent guidelines. In contrast to its larger neighbour, South Africa, the Botswana government has now set out to make as much of that treatment available as it can, though problems are already emerging in doing so.

A satellite meeting in Barcelona before the International Conference on AIDS heard from Botswana’s Health Minister, Joy Phumaphi, and from national and international experts, including people with HIV, on how Botswana is now responding to the challenge it faces. The meeting was sponsored by the African Comprehensive HIV/AIDS Partnerships, a collaboration between the government of Botswana, the Bill and Melinda Gates Foundation, the Merck Foundation and the Merck company. It is one of a number of remarkable international partnerships which have been assembled in response to Botswana's health and development crisis.

Botswana is one of the wealthier countries in Africa, and arguably one of the best governed. Unlike most of Africa, it has a stable democratic government, has not been at war, and has enjoyed consistently high rates of economic growth. What shocked Botswana’s politicians into action was the realisation that all of Botswana’s development gains over many years are now at risk. Life expectancy is plummeting and people who have been educated at great cost – education in Botswana is free, up to and including university level – are increasingly at risk of dying before they can make a contribution to society to repay that investment.

Botswana has had two successive national plans to respond to AIDS, yet the HIV incidence in the country has continued to rise to the point where in some districts more than half of the adult population (15 to 59) are HIV positive. Among women attending antenatal clinics, the national rate is now a shocking 38%. So why did these plans fail? And where does the country go next?

The view that emerged from the meeting is that the first plan was located entirely within the health system. While there was awareness raising around HIV and AIDS, this did not lead to major behaviour change.

In the second plan, it was recognised that the issue goes beyond health, and so there was discussion with other ministries and parts of society, but still most of the action was within the health system. Until 1999, less than a dozen people had gone public with their HIV status, despite the fact that people were dying. Uptake of counselling and testing was low and there was widespread fatalism alongside denial and stigmatisation of people with HIV.

With the third plan, which is being drawn up under a National AIDS Council headed by the country’s President, Festus Mogae, something far more ambitious is to be attempted.

Now, the thinking is that the response to AIDS is the “core business” of the entire government. This means that responding to AIDS is now to be integrated into the national development plan, at District level as well as with national government ministries. The Districts are then charged with reaching all communities and through them, every household in the country.

It is acknowledged that in responding to AIDS, through treatment and prevention, a country may still not really be dealing with what is causing the epidemic. Poverty/inequality, gender differences – and especially a lack of power on the part of women, and other cultural factors are the real cause of what has happened. These, then, need to be dealt with.

A concept of “total community mobilisation” has been launched in three districts, is being expanded to several more and will be taken nationwide. This involves one worker for every 2,000 people, who is charged with recruiting and supporting around 50 volunteers within that area, and with making face to face contact to talk about AIDS with everyone in that area at least once a year. Door-to-door counselling aims to break down the idea that AIDS is not an issue that anyone and everyone needs to respond to.

A national voluntary counselling and testing programme is being developed, with stand-alone centres set up in response to initial concerns from the community about having their status known in government health centres. However, as the demand for testing grows so a range of “satellite clinics” – some of them in those other health services – and mobile clinics will be supported. Some of the centres have actually been constructed by the US Army, on land provided by the Botswana government for the purpose.

Youth friendly services are a critical issue, given that teenage pregnancy rates are high and the majority of Botswana’s population, as in many developing countries, is very young. In schools, sex and relationships education is being taken to primary level.

A movement of people living with HIV and AIDS has now emerged in Botswana, with the slogan, “Nothing for us, without us”. This has physical bases in the form of AIDS Coping Centres and these provide a base for continuing counselling, education – including on treatments – and a range of practical support services.

An extensive programme to support orphans, including locally organised food provision to families caring for orphans, is being implemented. Already 31,000 orphans are registered with the programme, out of an estimated 65,000 in the country. Unfortunately these numbers are set to grow substantially.

A research programme has been established which is preparing to support clinical trials of HIV vaccines and microbicides, with a reference laboratory set up in Gaborone in partnership with Harvard University. The first vaccine trials are being planned, which will be closely related to those planned for South Africa.

Medical treatment which is already in place includes a programme that sets out to prevent mother to child transmission - 2,200 women already treated with AZT; a tuberculosis programme; and, now, the beginnings of antiretroviral provision for long-term treatment.

Dr Patson Mazonde reported on the priorities and progress of this new programme. Since its launch in January, 475 adults (58% of them women) and 30 children have been started on combination therapy through the public health service. (Others have previously been treated in Botswana through private healthcare.)

The priority that had been set was for women seen in antenatal clinics, and their partners, to keep parents alive to look after their children.

Despite the wealth that in Botswana comes mainly from diamond mining, cattle farming (it is a major beef exporter) and tourism, the country cannot afford to buy antiviral drugs even at currently discounted prices. It is therefore relying in large part on donations of drugs from companies, including Merck and Bristol Myers Squibb. One question that was asked, by a meeting participant from a neighbouring country, was how sustainable this could be and how difficult it would be to transfer to other poorer countries with larger populations. Clearly, large-scale international funding is needed.

However, the greatest challenge of all is about human resources. Until recently, Botswana did not even have its own medical school, so anyone who wanted to become a doctor had to be trained in other countries.

While Botswana has a well-established nursing school, there is now a desperate shortage of trained nurses. One problem is that many nurses are themselves HIV positive. Those who have not already become too ill to work are increasingly employed in HIV-related services and research projects (which may help them personally to access HIV treatment, as well as giving the potential for peer-support). Unfortunately, this is undermining other essential community health services – for example, immunisation of babies.

In the short term, Botswana is seeking to recruit both doctors and nurses from outside the country to work in HIV research and care. In the medium and longer term, this highlights a serious problem that many other countries will experience, if or when they make the same kind of commitment that Botswana has now made, in responding to the epidemic.

The number one message from the session: do visit Botswana. And if you're qualified, and able to stay around for a while, please feel free.