Botswana lagging behind Zim, Zambia in fight against HIV/AIDS

25 Sep 2017

With as much energy as President Festus Mogae spent fighting HIV/AIDS, as much money as the United States pours into HIV/AIDS programmes and as much airtime as that single HIV-free-generation advert gets on Btv, Botswana should be doing very well in the fight against this disease. It is not. A US State Department report shows that Botswana is not doing as well as two of its neighbours.

The not-so-inspiring news is contained in the President’s Emergency Plan for AIDS Relief (PEPFAR) 2017 Annual Report to Congress. PEPFAR was established in 2003 by President George W. Bush and has helped save millions of lives around the world. Its public health impact assessments show that the epidemic is becoming controlled in three key African countries: Malawi, Zambia, and Zimbabwe.

“These countries with continued focus are approaching a point where HIV transmission would effectively be controlled among adults and babies, and they have reduced new HIV infections by 51–76 percent since the start of PEPFAR. They currently have also achieved an average of 65 percent community viral load suppression among all HIV-infected adults, nearing the 73 percent target set by the Joint United Nations Programme on HIV/AIDS,” the report says.

PEPFAR identifies four general patterns of prevalence. The first includes prevalence curves that exhibit a generally flat profile based on a rate of new infections that is consistently greater than mortality; the flat trajectory is a result of new infections replacing those who died from AIDS-related diseases; the total burden of dis­ease remains constant, and costs are increasing as coverage of services increases. Countries in this category are Ken­ya, Lesotho, Mozambique, Namib­ia, South Africa and Swaziland. In the second category, new infection rates are slightly lower than or nearly equal to mortality rates; prevalence rates exhibit a downward trend, and there is a sustained decline in new infections; the disease burden is decreasing, cost increases are primarily driven by expanding service delivery coverage of combination pre­vention in high-transmission areas to ensure the rates of new infections remain in check; and out-year costs will begin to decline as the cohort ages. Countries in this category are Tanzania, Ethiopia, Ghana, Haiti, Malawi and Zimbabwe. The third category comprises countries with curves trending downward but not as sharp­ly as those in the latter category. Countries in this category are Botswana, Nigeria and Rwanda. The final category is of a single country (Uganda) with a prevalence rate that is trending upward, and with a new infection rate that is signifi­cantly greater than the mortality.

Alongside Rwanda, Botswana is said to have “excel­lent service coverage and marked decreases in deaths due to AIDS.” Indeed, Botswana’s AIDS mortality rate – which peaked at the beginning of the century, has been steadily declining since 2003. That should be good news but is not because “epidemic control has not been achieved due to the rate of new infections.” That would not come as a shock to Dr. Joep Lange, a prominent Dutch AIDS researcher who died in 2014 when the plane he was travelling in was shot down with a missile over Ukraine. Lange was a key figure in the development of the drug zidovudine (marketed under the brand name Retrovir) for AIDS therapy. An early AIDS researcher, Lange studied the Botswana situation very closely and ahead of the 2004 International AIDS Society (IAS) conference in Bangkok, Thailand, gave a keynote address at a workshop held in Amsterdam where he referenced the Botswana situation. He told his audience that anti-retrovirals were the only cost effective treatment for HIV and AIDS, especially that education alone didn’t work. With regard to the latter point, he gave Botswana an example where the epidemic had grown to be massive despite enormous efforts to raise awareness. Minutes of that meeting quote him as saying: “There is still widespread reluctance to use (male) condoms, which are still not as available as they need to be, and female condoms are not really an attractive alternative. Use of ARVs to prevent sexual transmission might be more likely to work than microbicides, and could incidentally be more woman controlled, but still need to be proven effective and safe for widespread use.” At this time he was IAS president and Botswana had the highest rate of HIV infection in the world.

Addressing the IAS conference proper the following year, Lange alerted the international community to the desperate AIDS situation in Southern Africa: “South Africa, Botswana and Swaziland will be potential basket cases if they don’t act, and in the case of Botswana, if it doesn’t act, it will cease to exist.”

While Botswana has been lauded as a success story in the fight against HIV/AIDS, there are those who question such assertion. A team of European Union consultants who worked on a tourism value chain report for the Private Sector Development Programme noted that Botswana’s HIV/AIDS strategy targets only two demographic groups (pregnant women and the youth) when there are many more at-risk groups that require similar attention.

In developing its strategy, Botswana learnt a lot of useful lessons from Uganda which used to be touted as Africa’s success story at the turn of the century. However, as the PEPFAR report shows, the East African country has been knocked off its pedestal and there is another lesson that Botswana has to learn from its experience.

“Uganda demonstrates how easily prog­ress can be reversed and previous gains lost. Bringing this expanded epidemic back under control is costly,” the report says.

Botswana’s mixed fortunes notwithstanding, the US adjudges the country to be among those that have the best chance of controlling their AIDS epidemic. Mixed fortunes cut across the board because even in Malawi, Zambia, and Zimbabwe, HIV incidence among young people, particularly women, remains “unacceptably high.” The PEPFAR report says that HIV prevalence increases significantly among those aged between 20 and 24.

“Significantly few young men and women under 25 are aware they are HIV infected and continue to infect others unknowingly.”

US president, Donald Trump, had sought to cut PEPFAR funding by $1 billion but that decision was voted down by Congress which will keep the funding at $6 billion. Given what he is, there will be nothing eyebrow-raising about Trump wanting to do that but what will be to some is that his predecessor, Barack Obama, also unsuccessfully sought to do the same thing. Like fellow Democrat Bill Clinton before him, Obama did not really do much for Africa. Bush did more for the continent than both men combined, a fact that former President Mogae half-acknowledged in an interview with a US TV channel.