TCS Daily

Combating AIDS on the Ground in Africa

By Richard Tren - November 18, 2003 12:00 AM

GABORONE, Botswana -- By the time Dr. Andrew Mujugira gets to work early in the morning the waiting room is packed full of patients. From as early as 6 in the morning, patients begin to queue up to seen by a physician, to have blood taken for tests and to pick up a month's supply of anti-retroviral pills. The patients at Princess Marina's HIV/AIDS clinic in Gaborone, Botswana sit in dignified silence, sometimes for hours, waiting for their name to be called. Most of them look healthy and robust, but there are some that look weaker and sicklier than you could imagine. Lucky for them that they live in Botswana and not anywhere else in southern Africa.


The recent resolution of the WTO's agreement on intellectual property (IP) rights and access to medicines is a welcome development, and the flexibilities could assist some countries that are seeking improvements to healthcare. Canada recently announced that it will change its IP laws to allow for the export of generic versions of patented drugs to poor countries. However Botswana's experience with AIDS treatment shows that an awful lot more than flexibility in intellectual property rights or well intended changes to Canadian law is needed to deliver drugs effectively.


Dr. Mujugira, a Ugandan who has been working in Botswana's public hospitals for some years, sees around 30 patients every day. Although he only has around 15 formal appointments, he can expect at least another 15 patients to just turn up at the clinic.


The Masa HIV/AIDS treatment centre has come about because of the Botswana Government's partnership with drugs company Merck, the Merck Company Foundation and the Bill and Melinda Gates Foundation. The African Comprehensive HIV/AIDS Partnership or ACHAP is unique in southern Africa. Masa means "new dawn" in Setswana and for thousands of Botswana that is exactly what it is.


Botswana has the highest rate of HIV infection in the world. With around 40% of the adult population living with HIV/AIDS the government took bold steps and showed a great deal of political will to tackle the problem. In many ways Botswana is fortunate. It has a stable, democratic government that supports the institutions of a free, open economy, such as private property protection and the rule of law. This has led to good long term economic growth. These policies, along with the enormous diamond reserves and a thriving cattle industry, mean that the country has the highest per capita income in Africa.


For many years the threat of HIV/AIDS went unnoticed in this small country. Yet between 1997 and 2001, life expectancy at birth has fallen from just over 47 years to around 38 years. Apart from the humanitarian disaster, the government and private sector clearly realised that HIV/AIDS would spell economic doom and undo the remarkable progress that the country has made.


The Botswana Way


Botswana's approach of partnering with the research based drugs companies seems to have paid dividends. Unlike its neighbours to the south, South Africa and to the east, Zimbabwe, the government clearly realised that if it wanted to make any meaningful impact it had to work with the research drugs companies.


Building the basic infrastructure, training staff, creating the logistical systems to deliver drugs and blood tests has been central to the success of the programme. Although the Masa programme got off to a slow start, it is now treating around 9000 patients at 6 clinics around the country. At the Princess Marina clinic, around 5000 are treated, probably more than any other clinic anywhere in the world. The treatment is free, as are consultations and blood tests.


One of the most serious impediments to AIDS treatment is stigmatisation. Two issues -- sex and death -- are difficult for almost anyone in any country to discuss and Botswana is no exception. With HIV/AIDS, those issues are combined. Apart from the dread of receiving the results from an HIV test, there is the added fear that if positive, one will be rejected by friends and family. So strong is this fear that patients will sometimes travel hundreds of miles to receive AIDS treatment in another town, and pay for it, rather than access the free treatment in a nearby clinic.


According to Dr. Mujugira, an attempt to test all the staff at the Masa Clinic in Gaborone was almost met with revolt. The nurses and other professional staff who treat people living with AIDS every day refused to be tested themselves. Dr. Pramitha Naidoo of ACHAP has developed innovative information and education programme that she hopes will go a long way towards removing the stigma associated with the disease. The fact that treatment is now available has also started to change perceptions about the disease. "I can now feel a change in the community" says Dr Ndwapi, a Botswanan who also works at the Princess Marina clinic.


Another problem that the programme faces comes from Government. The Masa programme struggles under a slow and unyielding bureaucracy that is hampering its expansion. For instance, it can take around 2 years to create a new position for a medical doctor in a public hospital. The inflexible government systems mean that the Princess Marina Masa clinic has been unable to hire more doctors. For instance and same number that used to treat 2500 patients now treat 5000. With only 5 permanent physicians at Princess Marina, each of them sees around 30 patients a day which makes their working conditions almost intolerable. Add to this the fact that the state employed doctors earn about a third of their private sector counterparts and you can understand why morale is low. There are other rules that hamper treatment. For instance blood has to be drawn by nurses, even though training phlebotomists to do the same would greatly lighten their load.


Attempts by a group of private physicians in Gaborone to lighten the load of the state hospitals and start treating patients for a fixed fee, has so far been met with silence from the government. According to Dr. Diana Dickinson, the group of physicians would have been able to treat around 7, 000 patients a year, but without Government cooperation they have been unable to do this.


Stigmatisation may take a long time to change, but cutting through the red tape should be quicker if -- and it's a big if -- the bureaucrats want to change. Unfortunately it is not within the nature of bureaucrats, the world over, to do themselves out of jobs or simplify the systems that they create and which keep them employed. As South Africa belatedly gets on with the job of trying to provide anti-retrovirals it can learn a lot from the mistakes and successes of its northerly neighbour.


Richard Tren is a columnist for and is a director of the South Africa based health NGO, Africa Fighting Malaria. He recently toured ACHAPs facilities in Botswana.

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