Botswana

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Background

Botswana lies in a region of Africa heavily burdened by HIV. It is among six countries in southern Africa that are the President's Emergency Plan for AIDS Relief (PEPFAR) "focus countries" (others include South Africa to the south and Namibia to the north and west). Along the Zambezi River to the north, it shares a border of only a few hundred yards with Zambia, another focus country. Zimbabwe, which is not a PEPFAR focus country, borders Botswana to the northeast.

Diamond, copper and nickel mining and beef exports are the country's main industries, though efforts are being made to diversify and expand the economy. Botswana supplies beef to the European Union, and its diamonds are shipped around the world.

A former British protectorate, the country gained its independence in 1966. Since then, it has experienced the most rapid growth in per capita income in the world. Unlike most African nations, Botswana has experienced almost continuous peace since its independence, which is key to implementing HIV/AIDS programs, according to Mary Kay Larson, deputy director of BOTUSA, a collaboration between the Botswana government and the U.S. Centers for Disease Control and Prevention (CDC).

"If you don't have security, you can't do much" Larson said. "Peace and stability are major, major factors of success."

The face of HIV

Almost all of Botswana's 1.7 million people are affected by HIV in some way. They are themselves infected, caring for someone who is or paying their last respects to AIDS victims. "People are always attending funerals," said Larson. In 2005 alone, about 18,000 people died from AIDS-related illnesses in the country.

Focusing resources on the high infection rate means other important issues are sometimes neglected. "You see it when you come back," said Larson, who left Botswana for about a decade before returning in 2004 to work for BOTUSA. "The high energy that used to be there just isn't around anymore."

Without AIDS, life expectancy in Botswana would be 72, according to the U.S. Census Bureau. While life expectancy is rising in most developed countries, it has declined drastically in Botswana since the HIV rampage began. It is now 34.

Challenges to fighting the HIV epidemic

With 70 percent of the country covered by the Kalahari Desert, Botswana's population is concentrated in a relatively small area. Eighty percent of the population lives along a highway that spans the eastern border. The rural population is more difficult to reach, but infrastructure has improved greatly, said Larson, who has worked in Botswana off and on since 1981. "A journey that used to take three weeks now just takes days."

As with many of the countries where PEPFAR, the five-year, $15 billion U.S. initiative to fight AIDS abroad, is targeting significant aid, a huge challenge is the insufficient number of trained medical professionals. Botswana does not have a medical school, and physicians are in short supply. However, unlike some other African countries, many Botswana students who receive medical training in other countries return home to practice.

Traditional healing is a popular alternative to costly Western medication. Lisa Lopez Levers, an associate professor of education at Duquesne University in Pittsburgh, Pa., says that Western doctors are often thought to be unfeeling and unwilling to spend time with patients, while traditional healers are often respected members of the community who consider it their job to listen to patients' concerns.

While Lopez Levers believes that traditional healers and Western doctors should work together to fight the epidemic, "in reality there is very little of that going on."

BOTUSA's Larson acknowledged that traditional healers have a broad reach in Botswana society. Often they are used alongside Western treatment, she said, and she noted that there have been collaborations with traditional healers in the past. She said that the Botswana government registers traditional healers and that there has been recent talk about working more closely with them in the future.

Botswana government response

The government has declared HIV a national emergency and has been "working hand-in-hand" with the U.S. government, said Larson. "There's strong political support, and the [Botswana] government has quite a bit of say in what happens and how it happens."

Beginning in 1992, the government started monitoring the HIV epidemic through annual study of pregnant women attending prenatal clinics. The data were used for program planning and raising awareness and support. The second generation surveys, first commissioned in 2003, tracked risky behaviors that may be fueling the epidemic, providing the link between behavioral and biological data.

It was also in 2003 that the government took the first steps to develop a comprehensive framework for fighting HIV/AIDS. The National Strategic Framework for HIV/AIDS 2003-2009 identified five intervention areas: preventing HIV infection; providing care and support; strengthening management of the national response to HIV and AIDS; mitigating the stigma and financial impacts of the disease; and developing a stronger legal and ethical environment.

In January 2002, Botswana became the first country to offer antiretroviral drugs to all citizens who need them. The drugs, distributed through the public health system, are credited with largely transforming HIV/AIDS from a fatal condition to a manageable illness. The costly program receives PEPFAR funding, supplemented by millions of dollars Botswana is pumping into it.

U.S. government response

In fiscal 2005, Botswana received $17 million for prevention activities, or 37.7 percent of the country's total PEFPAR funding for prevention, care and treatment. Another $12.3 million — or 27.2 percent — went to care, while treatment activities were allocated $15.9 million — or 35.1 percent.

BOTUSA was formed in 1995 to address a tuberculosis epidemic. In 2000, it added an HIV project and in 2002, it started HIV prevention and clinical testing that positioned the organization to receive PEPFAR funding.

In fiscal 2005, nearly 20 million in PEPFAR money went to various government ministries and departments — with more than 85 percent of it to the Ministry of Health.

The largest part of the government's portion is earmarked for prevention activities, such as programs to promote abstinence, blood safety, counseling and support to socially disadvantaged groups including orphans and vulnerable children. More than $100 million a year is spent on drugs. About 40,000 patients are receiving antiretroviral treatment, or ART.

The other avenue for channeling PEPFAR funds to the country is through the U.S. Embassy in Gaborone. The embassy works mainly through BOTUSA, but from time to time, it invites various user organizations and nongovernmental organizations (NGOs) that operate HIV/AIDS programs in the country to apply for funding.

Working with so many government agencies can be challenging, BOTUSA's Larson said. "You have the Botswana bureaucracy, the U.S. bureaucracy, PEPFAR, CDC, BOTUSA and the embassies."

Locally, availability of PEPFAR funds in recent years has spawned specialists in HIV/AIDS prevention and support services in fields such as counseling and testing, ARV purchases, ethics and law, and monitoring and evaluation.

The U.S. has sponsored a radio drama that deals with HIV issues to combat stigma and encourage people to lead low-risk lifestyles. The twice-weekly broadcast program is quite popular — it reaches almost half the population — and it is about to become its own NGO.

BOTUSA sponsors testing centers across the country that it touts as successful and wide-reaching. But Lopez Levers is skeptical.

The testing centers, she said, are not "culturally sensitive." "By and large, most of the people in Botswana are not going to go out and get tested, because this invasive testing is from a completely different medical paradigm from what they're used to," she said.

She stressed the need for cultural sensitivity, saying her research shows that "none of these programs bother talking with the village chiefs, the village elders" before implementation.

Larson disagrees. "Testing rates are extremely high," she said, "and they're increasing dramatically. [Testing centers] are run by local Botswana, and routine testing was introduced by the government."

According to the CDC Web site, 105,700 people had received counseling and testing by March 2005.

Larson and Lopez Levers agree that one area needing improvement is care and support of the country's 69,000 AIDS orphans. Larson said a U.S. Agency for International Development provides those services, but the country's program only recently hired a coordinator and it is not as developed as many of the other PEPFAR programs in place.

Maethasile Leepile contributed to this report from Botswana.

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