TCS Daily

A Miracle in Africa

By Roger Bate - August 5, 2004 12:00 AM

The AIDS epidemic in some parts of Africa is so severe and growing so quickly that hope seems impossible to find. But the African nation of Botswana is miraculously conquering despair and is on the verge of being the first African nation to do what not long ago seemed impossible: treating all those in need. The rest of the world will benefit by learning from Botswana's success.

At the XV International AIDS Conference in Bangkok last month, Botswana Health Minister Lesego Motsumi described that country's HIV/Aids program as sowing the seeds of hope for Africa. The program is on target, she said, to treat half those eligible, completely free of charge, by the end of 2005. Indeed, it is one of the world's biggest HIV/Aids treatment programs, with over 25,000 enrolled, over 15,000 patients indicated for therapy being treated, and more than 1,000 enrolling every month.

Critics of the plan had said that lack of capacity -- both human and infrastructure -- would mean that highly active antiretroviral therapy (HAART) would be too difficult to administer; that patients would not adhere to treatment schedules and resistant virus would emerge; and the stigma of AIDS, a lack of political will would prevent patients from coming forward.

To be fair, these concerns were fully justified by evidence from other African countries, but happily, Botswana has avoided the pitfalls and created a genuine success. The reasons for this success are in the differences.

On attaining independence from the British in 1966, Botswana rejected the socialist, strong leader model adopted by most post-colonial African countries. According to the official government website under the heading "The Gem of Africa," Botswana prides itself on following a constitutional, multi-party democracy operating on free market economic principles with diverse trading partners. The country's development plans were based on four national principles: democracy; development; self-reliance and unity, to which a fifth has recently been added: Botho (Setswana word for respect, good manners).

It is, of course, significant that soon after independence in 1966, Botswana discovered the best-quality diamonds in the world, and that Debswana, the mining company co-owned by DeBeers and the Botswanan Government, accounts for 70% of the country's exports. But, because of the country's strong sense of civic responsibility, Botswana has been spared the misery of having its wealth squandered or stolen by a self-serving élite.

The Botswanan government enacted its own AIDS program, Masa (meaning 'new dawn' in Setswana) in 2000 putting up its own money ($70 million a year) and designing the program to suit its own needs. This program has been supported and enhanced by the African Comprehensive HIV/Aids Partnership (ACHAP), a public­ private partnership between Botswana and the private charity, the Bill & Melinda Gates Foundation and Merck Company Foundation/Merck & Co. Inc., a private pharmaceutical company. The Gates Foundation pledged $50 million over five years, matched by Merck, which is additionally donating two anti-retroviral drugs. Drugs are also donated by GlaxoSmithKline and Bristol Myers-Squibb.

Masa, supported by ACHAP, has already created laboratory capacity to test and monitor patients' blood and a teaching clinic at the Princess Marina Hospital in Gabarone, where more than 1,000 healthcare workers have received hands-on, clinic-based training from international HIV/Aids specialists. By the end of 2004, the construction of 32 regional treatment centers should be completed, more than doubling the capacity of the 12 that are operational so far. It seems the perfect model: international expertise, capacity and goodwill are being used to maximum benefit by a government which took the first initiative. Added to this, the full burden is not being carried by the national program as private initiatives, by Debswana and others, treat a further 6,600 patients.

The operations director of Masa is Dr. Ernest Darkoh of Harvard and director of BroadReach Healthcare in Washington, DC. He says there is still much to be done in encouraging patients to turn up before they are sick, but he has attributed part of the success of the national program to a rejection of WHO procedural guidelines. These recommended counseling in a private room on the implications of HIV infection. Aside from the fact that psychologists and private rooms were simply not available, this "counseling" actually scared half of those attending into changing their minds about taking the HIV test.

The national AIDS co-ordinator, Dr. Banu Khan, also challenged the international guidelines and blames them for exacerbating the problem. "I think we created the stigma," she said. "The international guidelines from the World Health Organization and others told us to deal with it in strict confidentiality, and it became a different way of dealing with a communicable disease. Now we are trying to undo that stigma and make it more routine and more like any other disease."

Since January, the Ministry of Health has begun routinely testing everybody who presents at hospital for HIV, along with weight and blood pressure, unless asked not to. This will yield a double benefit: bringing more people forward for treatment and collecting more accurate data as to the real extent of HIV infection.

The importance of better data can't be overstated. Over the past year, assumptions have been challenged as the crude demographic model estimations used by UNAIDS and others have been overturned by real country data. The Kenya Demographic Survey, carried out by Kevin de Cock of the US Centers for Disease Control in 2003, found that, instead of the 15% prevalence assumed by UNAIDS, the true overall rate was 6.7%; but, even more significant was the difference between the male and female rates: 4.5% and 8.7% respectively. The crude assumption that men are infecting their wives, or even vice versa, is seriously challenged by these data.

Again, in South Africa only last week, the government's statistical service, Stats SA, reported that there were 1.5 million fewer HIV-positive people than UNAIDS had estimated (3.8 million, rather than 5.3 million). Sentinel surveys of pregnant women in Botswana were showing prevalence rates of around 38%, although these seem to have peaked and are now running at 34%. This is extremely high, and a very serious problem in itself, but the assumption that the total adult population is infected at these rates is highly suspect.

For Botswana, this may be another ray of hope. The population is only 1.7 million. Masa is working on the assumption that 300,000 are infected and has been frustrated that fewer than expected are coming forward for testing and free treatment. If the numbers have been overestimated to the same extent as they were in Kenya (i.e. by 100%), it is possible that by meeting current treatment targets by the end of next year, all those in need will be under treatment: that would be a miracle indeed.

Roger Bate is a visiting fellow of the American Enterprise Institute and Director of Africa Fighting Malaria and Lorraine Mooney is a medical demographer and Director of the European Science and Environment Forum in Cambridge, England.


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