Botswana tackles AIDS aggressively

When she looks at her daughter Gloria, who is plump, healthy, and smiling, Emily Pilane can't believe the difference.

Eighteen months ago, Gloria was in and out of the hospital, listless and ill. Her mother suspected AIDS.

Her hunch was correct. In August 2001, six months after Gloria tested positive, she was told she didn't have much time to live. Anywhere else in Africa, where an estimated 40 million people are believed to be infected, this may have been true. But in Botswana, the government has launched a radical program to provide free antiretrovirals (ARVs) - drugs that help combat HIV/AIDS - to everyone who needs them.

So Gloria, who shares a room with no electricity or running water with her mother and her 9-year-old son, now may see her boy grow up. "Always I'm counting the years until he finishes school," she says. "I never thought I would see it."

Most AIDS programs in Africa have focused on prevention - targeting funding at trying to stop people from getting the disease in the first place. But as countries begin coming to terms with the reality that huge percentages of their populations are already infected - here in Botswana, the figure is nearly 40 percent - pressure for treatment is mounting. In South Africa, for example, the Treatment Action Campaign is in the midst of a civil disobedience campaign aimed at forcing the government to pledge universal ARV treatment.

So far, most countries say they don't have the money or health resources to tackle the problem. But here in Botswana, which has become a test case for treatment in Africa, the government decided it couldn't afford not to do something. Hospital wards were overflowing with HIV-positive patients, overworked medical staff were fleeing, and the labor force that extracted the country's diamond wealth from the ground was dying from AIDS.

"In epidemiological terms, if you have a disease that affects 1 percent of any population, that's catastrophic," says Ernest Darkoh, operations director of Botswana's 15-month-old antiretroviral program, called Masa, after the Setswana word for "new dawn." "What we're dealing with here is uncharted territory."

The Princess Marina Hospital is a sprawling complex of yellow brick buildings set in the heart of this sparsely populated country's capital city. What was once an empty ward here has been turned into the country's first public HIV-care ward and a place where 3,000 people, including Pilane, come to get ARVs. There are now four such clinics around the country serving 6,000 patients. The government hopes there will be 13 by the end of the year.

In South Africa and elsewhere around the world, much of the debate over publicly available antiretroviral programs has focused on reducing the price of the drugs themselves. But building an effective ARV program is about more than handing out free drugs, say workers here. Clinics must be built, and doctors, nurses, counselors, and pharmacists hired. Even new computer systems to track patients must be created and installed in places that formerly lacked electricity.

According to Dr. Darkoh, the price for the drugs alone cost Botswana between $1,200 and $3,000 a year per patient. But during these first few years when new buildings are going up and new equipment is being purchased, the total price of the program is around $7,000 to $10,000 annually per patient. All together, the costs for the first year were $30 million. That is a steep price tag for most African countries, where many people live on less than a dollar a day. They say that although Botswana, with its diamond wealth, may be able to afford ARVs, they cannot.

"When you look at the press, the focus is always on drugs. But we had access to affordable drugs long before we had the infrastructure to implement this program," says Howard Moffat, hospital supervisor at Princess Marina. "Look at the new clinic," he says, referring to a building that will double the hospital's AIDS treatment capacity. "Once we had the approval, it took 15 months to build."

Some critics have complained that the program has moved too slowly to help most of the estimated 110,000 people here who need ARV treatment. There is a four- to six-month waiting period for all but the sickest patients. Many die before they reach the top of the list. The government says there is no room for mistakes because if they fail, it will affect the future of AIDS treatment across the continent.

Many people argued that a successful ARV program, which requires strict adherence to be effective, couldn't be done in Africa. But adherence rates here are 90 to 100 percent, as much as 20-percent higher than such rates at the most successful programs in the West. Doctors attribute this to the intensive counseling given to patients and to the effectiveness of the drugs. Many of the patients who start the program near death are healthy within months, and often back to work.

Although Botswana still faces many challenges, including the fierce stigma still associated with AIDS, the Masa program has invigorated Botswana's medical community and made it an international center of AIDS research.

Researchers and doctors from around the world are flooding in, expatriates are returning, and, in a country that doesn't have its own medical school, young researchers are learning to do state-of-the-art research in a newly built $3 million laboratory.

"What the government is doing here is very courageous," says Dr. Darkoh, a young, Harvard-educated Ghanaian. "We started this from zero, really from nothing."