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HIV & AIDS in Botswana
Botswana has been hard hit by HIV and AIDS. In 2011 there were an estimated 300,000 adults living with HIV – or one quarter of the population aged 15 and over. Considering Botswana’s population is only 2.1 million, the epidemic has reached disturbing proportions. The country has an estimated adult HIV prevalence among 15-49 year olds of 23 percent, the second highest in the world after Swaziland. 1
It is clear, however, that the national response to the epidemic is now bringing about positive results. Variations in Botswana’s life expectancy is a good indicator of this; after dropping from 64 years in 1990 2 to 49 years in 2002 3, life expectancy rose to 53 years in 2012 4. This rise can be attributed, in part, to the delivery of free HIV treatment (antiretroviral drugs) in 2001. The decision to provide antiretroviral treatment free through the public health service transformed treatment access from being only available to low numbers of people that could afford to buy their treatment, to being accessed by more than 95 percent of people in need. 5
Botswana has demonstrated that scaling up access to treatment is in the national interest. Now, however, they must commit to lowering new infections. Whilst new annual HIV infections have declined by 71 percent between 2001 and 2011, key issues are undermining present HIV prevention efforts; as a result, the number of new HIV infections reported per year has barely declined in recent years. 6 Currently, new annual infections are estimated at 9,000 cases. 7
With nearly a quarter of the population living with HIV, effective HIV prevention interventions are essential in Botswana. HIV affects all groups across Botswanan society. Key populations at risk of or affected by HIV include:
- Men who have sex with men
- Migrants and mobile populations
- Sex workers
- Orphans and other vulnerable children
- People with disabilities
- Women and girls
- Young women and young men
Targeted HIV prevention interventions currently exist, in varying degrees, for these groups. However, greater effort is needed if new HIV infection figures are to be significantly lowered. For many people, structural barriers continue to hinder access to HIV information and prevention services, and in some cases place them at a higher risk of HIV infection. For example laws prohibiting same-sex relationships and the lower social-status of women and girls.
Biomedical interventions, such as condom distribution and circumcision, alongside behavioural interventions, such as education about HIV prevention and safe sex, are also key to lowering new infections. These prevention approaches exist across Botswana in varying degrees.
In Botswana the spread of HIV is overwhelmingly reported as being through heterosexual sex rather than sex between men or injecting drug use. However, it is likely that HIV transmission through sex between men and injecting drug use are under-reported since they are illegal. 8
Sex education in Botswana is delivered primarily through school-based education. Despite this, it is clear that greater effort is needed to reach all Botswanans with information about HIV and how to protect themselves. Young people have particularly low knowledge about HIV, although this has risen steadily in recent years. HIV prevention interventions that deliver sex and HIV education to out-of-school young people have been identified as an area of need.
Knowing the facts about how to have sex safely at an early age can prevent you from acquiring HIV. It can also reduce new annual infections among the community, and in particular young people. AVERT has a number of pages for young people about a wide-range of issues including: sex, relationships, sexual attraction and living with HIV.
Access to HIV prevention methods
Access to knowledge is only part of HIV prevention. Access to condoms, circumcision services, treatment, and harm reduction services are essential to enable individuals to put their knowledge about HIV and safe sex into practice.
In 2009 the Ministry of Health distributed close to 20 million condoms while the charity Population Services International distributed almost 10 million. 9
For some, accessing or using HIV prevention methods can be difficult. The social status of women and young girls can make it difficult for them to negotiate condom use. 10 Moreover, laws that criminalise drug use deter people who use drugs from accessing harm reduction services. 11
Laws criminalising same-sex practices in Botswana particularly hinder men who have sex with men from accessing servces. Studies have found that MSM are reluctant to disclose their sexuality to healthcare providers, are unaware of the health services that are available and have experienced stigma and discrimination from healthcare providers. This has impacted negatively upon both the willingness and ability of MSM to receive HIV prevention, treatment and care services. 12 13
High-risk cultural traditions
Throughout Botswana certain traditions have been shown to increase the risk of HIV infection between people in long-term, heterosexual relationships. 14 One of these is the culturally accepted tradition of men having multiple and concurrent partnerships, as well as the common practice of inter-generational relationships and/or marriage. 15 Within this context, the difficulty women and young girls experience negotiating condom use, or refusing sex, greatly increases the risk of onward HIV transmission. Addressing gender inequality and high-risk cultural traditions such as these would go a long way towards lowering Botswana’s annual number of new HIV infections. 16
Prevention of mother-to-child transmission (PMTCT) of HIV
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 percent of all pregnant women. In the absence of any interventions, around a third of babies born to HIV-positive mothers will become infected with HIV during pregnancy and delivery or through breastfeeding. This rate can be cut substantially through the use of antiretroviral treatment and safer feeding practices.
- Less than one third of pregnant women are living with HIV 17
- Over 95 percent of all women and HIV exposed infants are covered by HIV PMTCT services 18
- HIV infections among children has reduced by 20-39 percent; from 700 new infections among children in 2009, to 500 in 2011 19
Test results from between November 2006 and February 2007 indicate that less than 4 percent of babies born to HIV positive mothers were infected, with this figure decreasing further to 3 percent in 2010 - a rate comparable with the USA and Western Europe. 20 21
Read more about preventing mother-to-child transmission of HIV worldwide.
Case study: HIV and the diamond mining industry
The success of the diamond mining industry has also been closely linked to the spread of HIV. A 2003 study in the densely populated mining town Selebi-Phikwe, showed an overall prevalence of 52.2 percent, 22 the highest in the country. The dangerous nature of this work means that many men view unprotected sex as a minor hazard relative to the day to day dangers of working in the mines. 23 Mining has shown to bring men into increased contact with multiple partners. 24 Sex work has become increasingly common around these richer mining towns as this offers the best livelihood for some young, poor and vulnerable women.
Case Study: Teacher-capacity building programme
In 2004, a teacher-capacity building programme was developed 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 the African Comprehensive HIV/AIDS Partnerships (ACHAP). The programme aimed 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 were equipped with a television, video recorder, satellite dish and decoder and an interactive AIDS education programme called Talk Back was broadcast twice weekly by Botswana Television. 25 Since its inception, Talk Back has reached more than 20,000 teachers and 460,000 students and won accolades for its services, including a nomination for the Commonwealth Education Best Practice Awards in 2009. 26 27
HIV testing in Botswana
Access to HIV testing and counselling continued to increase in 2010 with a total of 865 testing and counselling facilities across the country. 28 Two thirds of men and women (15-49 years) received an HIV test and their results in 2012. 29
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 U.S. Centre for Disease Control (CDC), through BOTUSA, have supported the Tebelopele network of VCT centres, which provide immediate, confidential VCT services for sexually active people in Botswana aged 18-49. By the end of 2009, the network had provided free VCT services to 650,000 visitors. 30
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. 31
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 counsellors and provided services to over 70,000 people. 32
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 enable people to access treatment at an earlier stage of disease. There is still a lot of stigma attached to sexually transmitted diseases in Botswana and officials believe this stigma can be reduced by treating the HIV test 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. 33
In the first six months of 2005, some 74,134 people were tested via the routine testing programme. 34
HIV and AIDS treatment in Botswana
Access to HIV treatment in Botswana has been steadily improving in recent years. Today, access is extremely high with more than 95 percent of all adults and children in need of treatment receiving it. 35 National treatment guidelines recommend providing treatment to patients with a CD4 count of <350 cells/mm3.
Botswana has also succeeded in testing and treating high numbers of pregnant women with HIV. Consequently, lowering the number of new HIV infections among children in 2011; considerably lower than other sub-Saharan countries. 36 Botswana is one of the few countries that has succeeded to provide more than 95 percent of children with HIV treatment. Currently, 194 clinics dispense ARVs. 37
Government and international funding for AIDS in Botswana
Botswana is facing a new funding challenge. Its classification as an upper middle-income country has resulted in the emergence of areas of financial need, as donors invest in lower-income countries. 38 It has transitioned from relying on donor funds to a country that is largely financially sustainable.
The government has succeeded in steadily increasing the amount of spending on HIV/AIDS; a total of $385.5 million was spent in 2011. Of this, $295.3 millions was from public funding sources. 39
International sources provided $90.3 million to the HIV response in Botswana in 2011; with bilateral sources accounting for the majority of funding. 40
Spending by programmatic area 41
- Prevention: 37.1 million
- Care and Treatment: 225.4 million
- Orphans and Vulnerable Children: 57.4 million
- Program Management and Administration Strengthening: 40.8 million
- Other: 8.5 million
An overwhelming amount of total funding is allocated to care and treatment in Botswana; indicating the financial commitment needed to achieve the high treatment coverage levels seen across the country. Whilst this is to be commended, the comparatively low amount spent on HIV prevention programmes is concerning.
The way forward
Botswana's national treatment programme (called “Masa”, a Setswana word meaning “a new dawn” 42
But the struggle to provide universal access to 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.
Providing treatment for an increasing number of HIV patients simply isn’t economically sustainable in the long term. After Botswana lost over half of an $18.6 million grant from the Global Fund to Fight AIDS, Tuberculosis and Malaria in 2008, resources were stretched to the limit, and Mogae warned:
“We are fast approaching a situation where we cannot afford what we are doing even now.” - Former President Mogae 43
This warning has been echoed by his successor President Ian Khama. Khama emphasised the responsibility of individual citizens, to ensure funding is not wasted, by reducing treatment failures through adherence to ARVs 44.
Antiretroviral treatment alone cannot solve Botswana's devastating HIV and AIDS crisis. In his address at the 17th International Aids Conference in Mexico 2008 former President Mogae stressed that whilst the government must remain committed to Botswana’s comprehensive treatment programme, hopes of ever overcoming AIDS in Botswana lie in halting transmission:
"Prevention of new infections should be our priority number one, priority number two and priority number three." - former President Mogae 45.
History of HIV and AIDS in Botswana
Botswana's first AIDS case was reported in 1985. The country's response to the emerging HIV and AIDS epidemic can be divided into the following 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. 46
- During the third stage (1997-2002), 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. 47
- Since 2003, a national multi-sectoral framework has guided the response, coordinated by the National AIDS Co-ordinating Agency.
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 across society including the public and private sectors, and civil society.
The First National Strategic Framework (2003-2009) spearheaded the multi-sectoral national response, explicitly outlining the implementation responsibilities of all partners and sectors involved and providing them with clear set of structures and guidance. During this time, a number of developments occurred including routine HIV testing, increased VCT centres and the provision of antiretroviral drugs through the public sector.
In 2009 Botswana completed its second National Strategic Framework which will guide its response to HIV and AIDS from 2010 until 2016. 48
"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.
History: HIV and AIDS treatment in Botswana
Addressing 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. 49 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. 50
The expected benefits were fourfold:
- To enable people with HIV to live longer, healthier lives
- To offer an incentive for HIV testing, and to lower the rate of HIV transmission
- To decrease the number of children orphaned each year by AIDS
- 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, former 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 that the programme would initially target four population groups: pregnant women with AIDS, HIV-positive child in-patients, HIV-positive people with tuberculosis, and adult in-patients with AIDS.
The national antiretroviral therapy programme was given the name MASA, the Setswana word 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. 51
When MASA started, 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. 52
But as MASA started to enrol more people during the year, 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. 53
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. 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. 54
It soon became 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. 55
The slowness of enrollment 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. 56
By January 2003 there were about 3,200 people enrolled in MASA. It was becoming clearer that although much had been accomplished, 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. 57
"It's mind-blowing. We're achieving miracles, and it's totally insufficient." - Dr Donald de Korte, ACHAP project leader. 58
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. 59 As a result, most of the doctors were foreign and did not speak the national Setswana language. 60
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. 61
HIV-related stigma and denial was also a major barrier to people accessing services. 62
"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. 63
"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. 64
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. Some observers argued the programme had been mismanaged and was not a good example for other African countries to follow. 65 An American newspaper reported that despite all the support it had received, Botswana's treatment programme was "barely making a dent". 66
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. 67 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. 68
"The response has been tremendous. People are coming forward and the sites are overwhelmed." - Dr Ernest Darkoh. 69
By the end of the year, it was estimated 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. 70
"What is even more heartening is that we are beginning to see a change in attitude. Botswana 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. 71
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. 72
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. 73 According to World Health Organisation figures, 85 percent of people in need of the drugs were receiving them at the end of the year, including those using the private sector. 74
How was such a rapid increase possible?
- 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. 75
- 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.
- 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 additional $3.3 million was expected from the Global Fund, $6.4 million from PEPFAR and $20 million from non-governmental organisations, charities and foundations. 76 In 2007, government spending on antiretroviral treatment totalled $31.3 million. 77
- Botswana has more money, better infrastructure and a better health system than most other sub-Saharan African countries.
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42. MASA ARV Programme'[/fn> 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.
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