The business of FIGHTING AIDS
Elvira van Niekerk
Published: 01-NOV-03

The HIV/Aids pandemic has Africa in its clutches, and if serious and drastic action is not taken, the continent will not only face a massive humanitarian disaster, it will also threaten its economic development. Elvira van Niekerk visited Botswana to see how this country, with the highest HIV/Aids prevalence rate in Africa, is tackling the problem head on.

Botswana is a beautiful country with rolling bushveld hills, abundant wildlife and friendly citizens.

When one drives through the capital Gaborone, one can see all the signs of a thriving economy - new shopping centres, office blocks under construction and many new vehicles on the road, to name by but a few.

However, underneath all this, Botswana is faced with a problem that can have serious implications on all this - HIV/Aids.

Out of a small population of only 1.7 million it is estimated that about 300,000 citizens are HIV positive.

Segolame Ramolhwa of the Botswana ministry of health's anti-retroviral treatment team explains some f the major impacts of the pandemic on the country.

"The biggest problem, off course, is that people are dying. Apart from this being unacceptable in humanitarian terms, that large numbers of our population are dying without government doing something about it - this causes many additional problems for the country."

He explains that the majority of sufferers are between the ages of 19 and 40 years. These are normally the people who contribute most significantly towards the country's economy. If suddenly, large numbers of these people die, it means that a significant part of the workforce disappear.

Many of these people also have small or school-going children who will become orphans dependent on the state if their parents should die.

Ramolhwa also explains that one must accept that a child that is brought up by his/her own parents has a significant advantage over an orphan in later life.

"It is therefore important for us to keep parents that are HIV positive healthy for as long as possible, so that they can see their children through school. In this way we hope to bring about a healthy and well-educated youth to drive our economy forward."

Another key issue that can be affected by a high HIV-positive rate is foreign investment. Any foreign investor would like to know that there is a healthy workforce available and not one that demands high medical costs and constant replacement and training.

Dr Banu Khan, co-ordinator of the Botswana National Aids Coordinating Agency at the Ministry of the State President states that a government of Botswana study conducted in 2000 shows that the estimated macro- economic impact of HIV/Aids over a 25 year period is that by 2021 the country's GDP would fall by 1.5 percent. This means that Botswana will have a GDP of 20 percent less than what it would have been without HIV/Aids.

A strategic plan

The first step that the Botswana government took in tackling the HIV/Aids problem was to thoroughly research it, and, based on these results compile a strategic national HIV/Aids policy.

When one pages through this plan, one recognises in it a serious business plan involving set targets, detailed budgets and specific time frames.

The five main goals of the Botswana National Strategic Framework for HIV/Aids (2003-2009) are:

  1. Prevention of HIV infection
  2. Provision of care and support
  3. Strengthened management of the National Response to HIV and Aids
  4. Psycho-social and economic impact mitigation
  5. Provision of strengthened legal and ethical environment.
A list of national objectives was compiled through a consultative process. This list include objectives such as:
  1. Increase the number of persons within the sexually active population to adopt key HIV prevention behaviours
  2. Decrease mother-to-child HIV transmission
  3. Decrease HIV prevalence in transfused blood
  4. Increase the level of productivity of people living with HIV/Aids
  5. Decrease the increase of TB among HIV positive patients
  6. Increase the number of skilled health workers

But how is a developing country, such as Botswana going to achieve this?

The answer - public-private partnerships. The African Comprehensive HIV/Aids Partnerships (Achap) - a partnership between the Botswana Government, the Bill Et Melinda Gates Foundation and the Merck Company Foundation (both of the US), is one such partnership.

Each of the American companies donated US$50 million over a five-year period to fighting HIV/Aids in Botswana.

On top of that Merck is donating all the anti-retroviral medication that is needed during this time.

Achap - in conjunction with the ministry of health has embarked on a several projects. These include condom research and distribution projects, the establishment of resource centres at district hospitals, the establishment of coping centres for people living with HIV/Aids, the Botswana Christian Aids Intervention Programme (Bocaip) councelling centres, the Masa antiretroviral (ARV) therapy programme, the Botswana-Harvard Aids Institute HIV reference laboratory, HIV/Aids training and the provision of medicines.


Implementing a project of this scale faces many challenges of which human resources is one of the biggest ones.

Botswana does not have a medical school and therefore cannot train its own doctors.

Doctors must therefore be trained elsewhere or employed from other countries such as Zambia or Nigeria, for example.

Trained nurses are also in short supply - but they are trained locally.

Apart from medical staff, for a project such as this one, ones needs skilled managerial and backup staff.

"One of the projects we are planning in Botswana is that of leadership training," says Brad Ryder of Achap.

He explains that Achap is investigating on what leadership and management skills and concepts can be borrowed from the private sector to help the public sector cope with this crisis.

"The National Aeronautical and Space Agency (Nasa) has a leadership programme which we believe can be used and adapted for our programmes," says Ryder.

He explains that it is of utmost importance to the success of the programme to implement proper leadership and management practices.

Infrastructure is another challenge.

It is one thing to promise people that treatment such as ARV-treatment will be available if there is no infrastructure available to support this.

Clinics need to be built and equipped. Part of this also includes developing and implementing a suitable information technology (IT) system.

The Botswana government is specifically developing a system whereby patients' information can be captured as well as checking if they use the medication.

At this stage, the local clinics in Botswana are computerised and a project is underway to connect all of the centres to a central database.

ARV treatment

The launching and implementation of an ARV-treatment project was well-researched and well-planned.

The ministry of health, in partnership with Achap and numerous private and public institutions, introduced the Masa ARV therapy programme to provide ARV medication to its citizens free of cost.

To allow the government to begin providing ARV therapy while concurrently enhancing capacity, the ministry of health has adopted a phased approach that began in early 2002.

With ARV-treatment being expensive and very specialised, it is necessary to have a detailed strategy in place, says Dr IMIapi Nlapi who works at the Princess Marina hospital in Gaborone.

Before one can even start ARV treatment, healthcare workers must be properly trained. Patients must also be educated on what ARV treatment is, how it works and what the issues around it are - such as what the side effects of the medication could be.

For ARV treatment to succeed people must adhere to medication and take it as it is supposed to be taken.

ARV treatment is extremely expensive and the Botswana government had to decide if it would be worth its while to make this treatment available to citizens.

Before implementing any projects, research was done by the McKinsey Company, based in the US, on what the possible demand would be for ARV treatment in Botswana.

Ramolhwa explains that although it is estimated that 300,000 people in Botswana are infected, only about 10 percent of those are aware of their status.

"When it comes to ARV treatment - we are only going to treat a small percentage of people of this 10 percent. It makes the initial numbers of people in need of ARV treatment much smaller. However, as people find out that they are HIV positive, we expect the numbers to increase."

It was therefore decided that in the first year of the project, about 10,000 people in Botswana will need ARV treatment.

Treatment groups were also prioritised.

"We couldn't afford to immediately make treatment available to all people with HIV/Aids - so we had to select who would be eligible first," explains Ramolhwa.

There are four priority groups:

  1. Pregnant women with a CD4 count of less than 200 and/or Aids defining illnesses, as well as qualifying partners who fulfilled the same criteria
  2. All HIV infected children older than six months who are in-patients at hospitals
  3. All HIV infected tuberculoses patients with CD4 counts persistently lower than 200
  4. All adult in-patients with CD4 counts under 200 and/or Aids defining illnesses.
Dr Nlapi explains that in January 2002 308 patients joined the pilot project for ARV treatment. Currently about 5,000 patients receive ARV treatment under the Masa project of which about 60 percent receive treatment from the Princess Marina Hospital.

He stresses that fighting the HIV/Aids battle is no easy task.

"One must realise that there is a big difference between what one would like to do and what is practically and financially possible. It is of utmost importance not to create false hope with HIV/Aids sufferers."

He believes that a lot of people believe that ARV treatment will cure them after they take it for a short while. They don't realise that it will only better the situation if taken as prescribed for the rest of the patient's life.

In Botswana people also initially though that all HIV/Aids sufferers will have immediate access to ARV treatment once the project rolled out.

"This wasn't possible at all. We had to phase the project, and help the sickest people first. We also didn't have enough trained staff to allow for a massive and immediate roll-out."

He warns other African countries that plan to embark on ARV-treatment projects to do so with caution.

"Do proper research, plan well and roll-out in a manner that is affordable, manageable and sustainable," concludes he.

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