Botswana is among the countries hardest hit by AIDS. In 2003 there were an estimated 350,000 people living with HIV. This, in a country with a total population below two million, gives Botswana an adult HIV prevalence rate of 37.3%, the second highest in the world after Swaziland.

Botswana was the first African country to aim to provide antiretroviral therapy (ARV) to all its needy citizens. Many believe that if anywhere in Africa is going to succeed in implementing such a comprehensive HIV/AIDS care and treatment programme, then it is Botswana. This Southern African country has enjoyed unbroken peace since gaining independence in 1966, and has become relatively prosperous thanks to its diamond mines, though much of the population remains in extreme poverty.

Botswana's first AIDS case was reported in 1985. At that time AIDS was seen as a disease that affected male homosexuals in the West and people from other African countries.

Botswana's response to the HIV and AIDS epidemic can be divided into three stages. The early stage (1987-89) focused mainly on the screening of blood to eliminate the risk of HIV transmission through blood transfusion. The second stage (1989-97), and the first Medium Term Plan (MTP), saw the introduction of information, education and communication programmes, but the response was still quite narrowly focused.

During the third stage (1997 onwards), the response to HIV/AIDS was expanded in many different directions to include education, prevention and comprehensive care including the provision of antiretroviral treatment, with the overall goal of not only reducing HIV infection and transmission rates, but also reducing the impact of HIV and AIDS at all levels of society.

The National AIDS Co-ordinating Agency (NACA) was formed in 1999 and given responsibility for mobilising and coordinating a multi-sectoral national response to HIV and AIDS. NACA works under the National AIDS Council, which is chaired by the President and has representatives from 17 sectors including civil society, the public sector and the private sector.

Early in 2001 the Government decided to initiate a rapid assessment of the feasibility of providing antiretroviral drugs through the public sector. The treatment programme began at a single site in January 2002, and after a slow start expanded rapidly during 2004, so that around half of those in need were receiving medication by the end of the year.

Prevention programme

There are a number of different types of HIV prevention programme currently taking place in Botswana. These include:

Public education & awareness

Public awareness and education has previously been based on the “ABC” of AIDS: Abstain, Be faithful and, if you have sex, Condomise. One recent initiative has been the development of a radio drama ‘Makgabaneng’ dealing with culturally specific HIV/AIDS-related issues and encouraging changes in sexual behaviour. Another initiative has involved workplace peer counselling, including the development, piloting and distribution of a facilitator's manual. HIV education has been taken to people's doorsteps by the Total Community Mobilization programme.

Education for Young people

It is crucial that young people be provided with HIV education and prevention messages to help protect them from infection. Among those performing this role in Botswana is the Youth Health Organisation (YOHO), a youth-run non-governmental organisation that conveys its messages through art festivals, dramas and group discussions. School-based learning plays one of the most important parts in educating young people about HIV and AIDS, and Botswana-specific HIV/AIDS materials have been developed for students with the Ministry of Education.

A teacher-capacity building programme has been developed jointly by the Ministry of Education of Botswana and the United Nations Development Programme (UNDP), in collaboration with the Government of Brazil and with support from ACHAP. The programme is trying to improve the teachers' knowledge, to demystify and destigmatise HIV/AIDS, and to break down cultural beliefs about sex and sexuality.

Condom distribution

Successful social marketing and subsidisation have substantially increased condom use in Botswana. Population Services International (PSI) has helped to promote the 'Lovers Plus' condom since 1993 and the 'Care' female condom since 2002. One of PSI's key strategies for marketing condoms has been peer education, which has been conducted in a variety of settings such as fairs and festivals, shopping malls, workplaces and bars.

In 2003 the Government of Botswana, with funding and technical support from ACHAP, launched an extensive condom distribution and marketing campaign, providing for the installation of 10,500 condom dispensers in traditional and non-traditional outlets throughout the country. Millions of condoms have been procured for free distribution.

Targeting of highly mobile populations

Highly mobile populations, including migrant workers, are often especially likely to be exposed to HIV. Therefore the Botswana Government, American Government agencies, NACA, ACHAP and several other partners are initiating a prevention programme linked to the Corridors of Hope project (which is also being implemented in other Southern African countries).

The programme will target all highly mobile populations nationwide, concentrating on the treatment of sexually transmitted infections, condom promotion and prevention education. One key focus will be on encouraging safe sex practices through peer education and outreach activities.

Improvement of blood safety

The Ministry of Health, the Safe Blood for Africa Foundation and other partners, with funding from ACHAP and PEPFAR, have helped to improve the safety of blood transfusions in Botswana. The national supply of HIV-free blood doubled in size in the two years up to September 2005. Over the same period, the amount of HIV-infected blood given by donors fell by half, largely because of better screening of donors and counselling.

One of the projects contributing to the improvement in blood safety is called "Pledge 25". This project recruits young people to become blood donors and teaches them how to prevent HIV infection. The young people are encouraged to pledge to donate blood 25 times during their lifetime.

Prevention of mother to child transmission of HIV (PMTCT)

In the absence of any interventions, around a third of the babies born to HIV-positive mothers will become infected during pregnancy and delivery or through breastfeeding. This rate can be cut substantially through the use of antiretroviral treatment and safer feeding practices.

A prevention of mother-to-child transmission (PMTCT) programme was the first programme to distribute antiretroviral drugs in Botswana, with the drug Zidovudine (AZT) being provided free by the company GlaxoSmithKline. However, early enrolment of women in PMTCT programmes was disappointingly low, in the range 11-20%, and this was blamed on a shortage of staff and inadequate infrastructure. The Government responded with training and recruitment programmes for PMTCT counsellors.

The status of women in relation to men creates further problems. Many women lack the power to control decisions about sexuality, and remain under the authority of their husbands, parents and in-laws all their lives. A woman who returns to her community with formula milk for her baby risks being stigmatised, as formula feeding can identify her as HIV-positive.

Recently, PMTCT efforts have expanded considerably, and services have been established in all public facilities through the Maternal Child Health/Family Planning system, which serves over 90% of all pregnant women.

HIV testing & counselling

Voluntary HIV counselling and testing (VCT) plays a key part in HIV-related prevention and care. It is particularly important as a starting point for accessing other HIV/AIDS-related services.

Since 2000, the Government of Botswana and the CDC (through BOTUSA) have supported the Tebelopele network of VCT centres, which provide immediate, confidential VCT services for sexually active Batswana aged 18-49. By October 2005, the network had expanded to sixteen centres and eight satellites, and had provided free VCT services to over 230,000 visitors. Tebelopele became an independent non-governmental organisation in 2004.

Routine testing

Since the beginning of 2004, HIV tests have been offered as a routine part of checkups in public and private clinics in Botswana. The testing is part of the standard routine but people who do not want to be tested can opt out.

Botswana was the first country in Africa to have a national policy of routinely offering an HIV test at clinics. Health officials believe that routine testing is a good way to help prevention programmes and to lessen the burden on hospitals by helping people to access treatment at an earlier stage of disease. There is still a lot of stigma attached to sexually transmitted diseases in Botswana. Officials believe this stigma can be reduced by treating the HIV test just like any other routine medical procedure.

In the first six months of 2005, some 74,134 people were tested via the routine testing programme.

HIV/AIDS treatment

In August 2000, President Festus Mogae said that new funding from ACHAP would allow his country to provide antiretroviral therapy to all HIV-infected pregnant women and children born with the virus. In March 2001, the President announced his Government hoped to implement a national treatment programme before the end of the year. The Government was conducting a needs assessment, and would pay a "substantial" portion of the programme's costs.

The expected benefits were fourfold:

  • To enable people with HIV to live longer, healthier lives
  • To offer an incentive for HIV testing, and to lower the rate of HIV transmission
  • To decrease the number of children orphaned each year by AIDS
  • To maintain skills in the workforce necessary for economic development

This was the first time any African country had proposed such an ambitious programme, and some doubted whether it was really feasible.

By January 2002, the aim was to provide medication during the coming year to 19,000 of the 110,000 infected people whom it was considered could benefit. As a result of poor resources - laboratory capacity, staff and infrastructure - it was decided to initially target four population groups: pregnant women with AIDS, HIV-positive child in-patients, HIV-positive people with TB, and adult in-patients with AIDS.

The national antiretroviral therapy programme was given the name MASA, the Setswana word for "dawn", and the first antiretroviral drugs were provided at the Princess Marina Hospital in Gaborone in January 2002.

By June 2002, an estimated 1,000 people had been enrolled in MASA. Of these, 500 were on therapy, while the remainder were having their requirements assessed. Although the numbers were disappointingly small, the indications were that few people were having difficulty adhering to the antiretroviral regime. There had been a major concern that poorly educated people would struggle to understand the importance of taking the complex cocktail of drugs on time for the rest of their lives.

The introduction of antiretroviral therapy had required broadening the infrastructure including testing centres and storage facilities, equipping existing clinics and hospitals and training medical personnel. The shortage of staff was the single biggest constraint on treatment scale-up. Many skilled professionals had been lured away from Botswana's public health system by offers of better pay and benefits, and some had moved abroad. To compensate, Botswana recruited workers from poorer parts of Africa, as well as from India and Cuba. As a result, most of the doctors were foreign and did not speak the national Setswana language.

When each new site opened, many of the first patients to enrol were already very sick, and so required a lot more time and resources. HIV-related stigma and denial was also a major barrier to people accessing services. As 2003 drew to a close, MASA was still a long way short of the 19,000 target originally set for the end of 2002, and some observers argued the programme had been mismanaged, and was not a good example for other African countries to follow.

By September 2005,54,378 people were receiving treatment. 4,582 children were receiving treatment through MASA by the same date. A study published in November 2005 found that the first patients to receive treatment through MASA experienced "excellent" responses, comparable with those seen in the developed world. However drug toxicity was a significant problem, and led to changes in the drug regimen.

  • Routine testing has increased demand for treatment, especially among people without symptoms.
  • A social mobilisation campaign has raised awareness of the availability and effectiveness of antiretroviral treatment, and has helped to reduce stigma and discrimination. Once people see for themselves how therapy has benefited others, they become more eager to seek services.
  • The programme has been well supported. As of mid-2005, Government expenditure on treatment scale-up was expected to be around $62.1 million in 2004-5. An additional $3.3 million was expected from the Global Fund, $6.4 million from PEPFAR and $20 million from non-governmental organisations, charities and foundations.
  • Botswana has more money, better infrastructure and a better health system than most other sub-Saharan African countries.
  • The Princess Marina Hospital in the capital Gaborone was the largest single provider of antiretroviral therapy in Africa, and 31 other sites in Botswana were offering free treatment, including at least one in each of the 24 health districts. About three quarters of those receiving treatment are doing so through the public sector, but an increasing number of private companies were also offering treatment to their employees

Botswana's national treatment programme is now seen as a successful model for other African countries to follow. Though progress was initially slower than expected, the programme made rapid progress in 2004 and 2005, and patient responses have been comparable to those seen in Europe and the USA.

MASA has demonstrated that antiretroviral treatment can be provided on a national scale through the public health system of a sub-Saharan African country - not just through localised projects run by foreign aid workers or researchers. In Botswana's case, almost all of the actual cost of treatment has been paid by the Government, while other partners have given support by providing laboratory equipment, staff training or patient monitoring services.

But the struggle to provide universal treatment in Botswana is far from over. In the first place, there are still thousands of people dying because they are not receiving the medicines. In addition, all of those already enrolled must continue to receive drugs and monitoring services for the rest of their lives, and people who develop resistance to their current medications must have access to alternatives, which can be more expensive and complex than first-line therapy.

It is much easier to provide treatment in towns than in rural areas, and MASA will need to be rapidly decentralised to ensure that all districts are covered. The shortage of skilled staff will continue to be a great challenge to MASA, and the programme will continue to be very expensive. The need for help from the rest of the world is as urgent as ever.

Even if universal access is eventually achieved, antiretroviral treatment alone cannot solve Botswana's devastating HIV and AIDS crisis. Botswana's long-term vision is to have no new HIV infections by 2016, when the nation will celebrate 50 years of independence. This will never be achieved without a massive and sustained HIV prevention campaign.