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Introduction

Botswana is among the countries hardest hit by AIDS. In 2005 there were an estimated 270,000 people living with HIV. This, in a country with a total population below two million, gives Botswana an adult HIV prevalence rate of 24.1%, the second highest in the world after Swaziland. (An earlier UNAIDS estimate of 37.3% prevalence in Botswana is now thought to have been too high.)¹

Life expectancy at birth fell from 65 years in 1990-1995 to less than 40 years in 2000-2005, a figure about 28 years lower than it would have been without AIDS.² An estimated 120,000 children have lost at least one parent to the epidemic.³ In an address to the UN assembly in June 2001, President Festus Mogae summed up the situation by saying:

"We are threatened with extinction. People are dying in chillingly high numbers. It is a crisis of the first magnitude." - ⁴

Botswana was the first African country to aim to provide anti-HIV drugs 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 Gross Domestic Product in 2004 was almost as high as that of Mexico.⁵

"Botswana can be seen as a leader in efforts to combat the epidemic and there is no other option but success. It must be remembered by all that what is done here will serve as the foundation of a renewed and agressive response to the epidemic in the sub-region, the continent, and beyond." - Botswana National HIV/AIDS Strategic Framework 2003-2009.⁶

History of HIV/AIDS in Botswana

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 this stage, in 1993, the Government adopted the Botswana National Policy on AIDS.⁷

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. The second Medium Term Plan (MTP II) aimed to involve many stakeholders who had previously been excluded, 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.⁸

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.⁹

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. By the end of 2006, almost all of those in need were receiving medication.¹⁰

In 2003 Botswana completed a National Strategic Framework which will guide its response to HIV and AIDS until 2009.¹¹

Who helps Botswana to fight its epidemic?

Most funding for HIV/AIDS programmes in Botswana is supplied by the national government, which spent around $150 million in 2005 (six per cent of the national budget).¹² The most significant initiatives supported by foreign donors are the African Comprehensive HIV/AIDS Partnerships (ACHAP) and the BOTUSA project.

ACHAP is a collaboration between the Government of Botswana, the Bill & Melinda Gates Foundation and the Merck Company Foundation. ACHAP was established in July 2000 and is dedicated to supporting Botswana's HIV/AIDS response through 2009. The Bill and Melinda Gates Foundation and the Merck Company Foundation have each committed $50 million towards the project, and Merck is also donating two antiretroviral drugs. As of June 2005, ACHAP's total programme spending was just over $41 million.¹³

In 1995 the US Centers for Disease Control and Prevention (CDC) and the Botswana Government began a collaboration called BOTUSA, to work on public health research and programmes to combat TB as well as HIV/AIDS. BOTUSA has grown substantially since 2000, and is now part of the President's Emergency Plan for AIDS Relief (PEPFAR).¹⁴ PEPFAR contributed $55 million to HIV/AIDS programmes in Botswana in Fiscal Year 2006 alone.¹⁵

With help from these and other partners - including the Global Fund, the Harvard School of Public Health, the Bristol-Myers Squibb Foundation, and numerous faith-based and community-based organisations - Botswana is mounting one of Africa's most comprehensive programmes of HIV/AIDS prevention, treatment and care.

HIV prevention

There are a number of different types of HIV prevention programme currently taking place in Botswana. These include:

• Public education & awareness
• Education for young people
• Condom distribution & education
• Targeting of highly mobile populations
• Improvement of blood safety
• Prevention of mother-to-child transmission of HIV (PMTCT)

Public education & awareness

Public awareness and education has previously been based on the "ABC" of AIDS: Abstain, Be faithful and, if you have sex, Condomize. Botswana has safe-sex billboards and posters everywhere, but it is unclear whether anyone pays attention.

"This country has been bombarded with HIV messages, but there hasn't been a change in behaviour." - Oscar Motsumi, programme officer in Serowe.¹⁶

So now the aim is to target the right message to the right people. 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. And HIV education has been taken to people's doorsteps by the Total Community Mobilization programme.¹⁷

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.¹⁸

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. As part of the project, all primary and secondary schools have been equipped with a television, video recorder, satellite dish and decoder, and an interactive AIDS education programme called Talk Back is broadcast twice weekly by Botswana Television.^{19 20}

Condom distribution & education

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.²¹

In 2003 the Government of Botswana, with funding and technical support from ACHAP, launched an extensive condom distribution and marketing campaign, providing for the instalation of 10,500 condom dispensers in traditional and non-traditional outlets throughout the country. Millions of condoms have been procured for free distribution.^{22 23}

Targeting of highly mobile populations

Highly mobile populations, including migrant workers, are often especially likely to be exposed to HIV. Therefore the Bostwana 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.²⁴

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 HIV-infected 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.²⁵

Prevention of mother-to-child transmission of HIV (PMTCT)

The 2002 survey of pregnant women attending antenatal clinics in Botswana found an average HIV prevalence rate of 35.4%.²⁶ In the absence of any interventions, around a third of 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.²⁷ When early enrolment of women in PMTCT programmes was disappointingly low,²⁸ the Government responded with training and recruitment programmes for PMTCT counsellors, and later with routine HIV testing of all pregnant women. HIV positive mothers who choose to avoid breastfeeding are given a year's free supply of infant formula.

Thanks to the commitment of the Government and its partners, Botswana's PMTCT programme is now one the most effective in the developing world. Services have been established in all public facilities through the Maternal Child Health/Family Planning system, which serves over 90% of all pregnant women. Test results from between November 2006 and February 2007 indicate that less than 4% of babies born to HIV positive mothers were infected - a rate comparable with the USA and Western Europe.²⁹

AVERT.org has more about preventing mother-to-child transmission of HIV worldwide.

HIV testing and counselling

Voluntary testing

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.^{30 31}

The Tebelopele centres have been supported by the "Know Your Status" and "Show You Care" campaigns, part of the VCT marketing strategy developed by the CDC in collaboration with Population Services International (PSI). These campaigns have been marketed through billboards, bus stops, banners, print advertisements and regular radio programmes throughout Botswana.³²

ACHAP in partnership with the Botswana Christian AIDS Intervention Programme (BOCAIP) has established eleven additional counselling centres. By September 2005, these centres had offered training to 447 counselors and provided services to over 70,000 people.³³

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.

"Our single largest problem is the lack of knowledge of HIV status... When you have that many people who don't know their status, anything could happen. If each person infected another person, they you could have 35 prevalence turn into 70 percent prevalence. It's insane." - Dr Ernest Darkoh.³⁴

In the first six months of 2005, some 74,134 people were tested via the routine testing programme.³⁵

HIV/AIDS treatment

The need for 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.³⁶ 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.³⁷

The expected benefits were fourfold:

1. To enable people with HIV to live longer, healthier lives
2. To offer an incentive for HIV testing, and to lower the rate of HIV transmission
3. To decrease the number of children orphaned each year by AIDS
4. 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.

"We see before us the most dramatic experiment on the continent. If it succeeds, it will give heart to absolutely every country worldwide." - Stephen Lewis, UN Special Envoy for HIV/AIDS in Africa.

The birth of MASA

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 world for "dawn", and the first antiretroviral drugs were provided at the Princess Marina Hospital in Gaborone in January 2002. ACHAP is a key partner in the programme providing extensive financial and technical assistance.³⁸

By the time of the start of MASA, there were already warnings about the financial sustainability of the programme. It was estimated that it would cost US$24.5 million to include 19,000 people in 2002 (around $1,300 per patient), and then an additional 20,000 people would be admitted each year.

"The programme is most likely not sustainable at that level. Our hope is that over time, as the anti-AIDS messages sink in - our youth are starting to listen - the rate of infections will fall and there will be a smaller number of people needing the drugs." - President Mogae.³⁹

But as MASA started to enrol more people during the year, so other problems became apparent.

"We are short of doctors. We are short of nurses. We are short of pharmacists. We are short of health technicians." - President Mogae.⁴⁰

Challenges faced during treatment scale-up

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. To help people with adherence, NACA came up with a "buddy system" whereby each patient is encouraged to form a special bond with someone close to them, who makes sure that they follow their medication schedule. The patients in turn counsel others to come forward for testing and treatment.⁴¹

By September 2002, the numbers had increased to 2,200 enrolled at four public hospitals of whom 1,500 were on treatment.⁴² It had become clear that enrolling people was a lengthy process. It involved counselling at testing centres, screening blood once a person knew their status, taking a white blood cell count and then eventually enrolling in the programme. 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. But the shortage of trained staff was still acute.

"The bottom line is: we need help. 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." - Dr Khan, head of NACA.⁴³

The slowness of enrolment was also adding to the pressure on existing staff.

"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?" - Dr Moffat, superintendent of the Princess Marina clinic.⁴⁴

By January 2003 there were about 3,200 people enrolled in MASA. It was becoming clearer that although much had been acomplished, much more remained to be done.

"You could provide treatment under a tree if you had to. It's follow-up and continuity of care that is the real work." - Dr Ernest Darkoh, operations manager of MASA.⁴⁵

"It's mind-blowing. We're achieving miracles, and it's totally insufficient." - Dr Donald de Korte, ACHAP project leader.⁴⁶

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.⁴⁷ As a result, most of the doctors were foreign and did not speak the national Setswana language.⁴⁸

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.

"If you spend all your time and capacity on the very sick people, you can never get to those who are not sick, and unfortunately, that sets up a loop of perpetually insatiable demand." - Dr Ernest Darkoh.⁴⁹

HIV-related stigma and denial was also a major barrier to people accessing services.⁵⁰

"People are still reluctant to come forward to be tested. They don't come forward because of the fear of discrimination and the stigma associated with HIV. And unless you're tested, you don't know whether or not you're positive and therefore might benefit from treatment." - Dr Linda M. Distlerath, Merck's Vice-President for Global Health Policy.⁵¹

"I'm very frustrated. We think because of the stigma attached to this sexually transmitted virus, and because some of our religious people have said this is a curse or those who have it are sinners, that people are afraid to get tested." - President Mogae.⁵²

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.⁵³ An American newspaper reported that despite all the support it had received, Botswana's treatment programme was "barely making a dent".⁵⁴

Botswana's treatment success

The number of people receiving antiretroviral treatment through the public sector continued to rise gradually during 2003, reaching around 8,000 at ten clinics by the end of the year.⁵⁵ Then in 2004 MASA entered a new stage of rapid expansion.

By May 2004, more than 24,000 people had been enrolled on MASA, of whom 14,000 were receiving antiretroviral treatment.⁵⁶

"The response has been tremendous. People are coming forward and the sites are overwhelmed." - Dr Ernest Darkoh.⁵⁷

By the end of the year, UNAIDS/WHO estimates showed that between 36,000 and 39,000 people were receiving antiretroviral treatment, including those using the private sector, who made up around one quarter of the total. MASA was achieving good rates of treatment adherence in terms of self-reporting, pill counts and attending scheduled appointments, and this was confirmed by measuring viral load suppression.⁵⁸

"What is even more heartening is that we are beginning to see a change in attitude. Batswana are finally understanding that regardless of their HIV status they have viable options available to them to continue seeking and living fulfilled lives." - Dr Ernest Darkoh.⁵⁹

By June 2005, the total had risen to 43,000 people receiving treatment - more than half of the 75,000 in need, according to the World Health Organisation. 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 were doing so through the public sector, but an increasing number of private companies were also offering treatment to their employees, including the Botswana Power Corporation and Barclays Bank.⁶⁰

By September 2005, according to Health Minister Sheila Tlou, the total number on treatment had reached 54,378, and 4,582 children were receiving treatment through MASA.⁶¹ According to World Health Organisation figures, 85% of people in need of the drugs were receiving them at the end of the year, including those using the private sector.⁶² Coverage exceeded 95% by the end of 2006, when around 84,000 were receiving treatment.⁶³

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.

"This data confirms what we are starting to see throughout the developing world. Patients will do fine regardless of social and economic status, provided the necessary infrastructure and funding are in place." - Professor Richard Marlink, Harvard School of Public Health.⁶⁴

"Mortality has gone down. There is a real decrease." - Dr Sheila Tlou, Minister of Health.

"We are so grateful. These days we are burying old women again [instead of young people]." - a village chief.⁶⁵

How was such a rapid increase possible?

When considering the progress of MASA, there are a number of factors worth taking into account:

• Experience shows that the number of people on treatment at each site does not grow at a uniform rate. Expansion starts slowly then accelerates as the local health workers gain confidence, commitment and experience, and as organisational "teething problems" are overcome. Eventually the rate of growth will slow down again as everyone in need is enrolled.⁶⁶
• 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 addtional $3.3 million was expected from the Global Fund, $6.4 million from PEPFAR and $20 million from non-governmental organisations, charities and foundations.⁶⁷
• Botswana has more money, better infrastructure and a better health system than most other sub-Saharan African countries.
• Ways were found to ease the shortage of trained staff, as explained below.

Easing the shortage of trained staff

In 2000, the Harvard AIDS Initiative and the Botswana Ministry of Health set up the KITSO Training Program, which provides training in HIV and AIDS care tailored specifically for Botswana's health professionals. Participants are allowed to remain in their posts while receiving the training, so as not to leave their clinics even more short-staffed. Major support for KITSO is provided by ACHAP.⁶⁸ By September 2005, KITSO had trained 1,941 health care workers in HIV/AIDS clinical care fundamentals.⁶⁹

Another important development has been the clinical preceptorship programme. This scheme brings HIV specialist doctors from the USA and Europe to work in Botswana for periods of at least three months, providing hands-on training to local medical staff.

The Government also pays private doctors to test for infection, carry out the laboratory work, and supply treatment to people unable to access it through the public sector, particularly those in rural areas. And NACA has tried to develop a system of lay counsellors to ease the workload of some nurses.

"Even when I did find a doctor willing to come to the country, [he or she] wasn't willing to live in remote rural areas... So the answer must be that we use already existing people who are living in these communities - in new and creative ways." - Dr Ernest Darkoh.⁷⁰

The way forward

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.

"The Government of Botswana has demonstrated a very high level of political commitment to addressing the HIV/AIDS epidemic... Botswana's success provides a fine example of how antiretroviral therapy can be provided on a large scale in resource-constrained settings." - World Health Organisation.⁷¹

But the struggle to provide universal treatment in Botswana is far from over. 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 further decentralised to ensure that all areas 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.

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.

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