Model treatment programme has its problems

When the Botswana government decided to provide free antiretroviral (ARV) treatment to its HIV-positive citizens, the country was hailed for taking such a bold step at a time when some of its neighbours continued to debate the toxicity of the drugs and wrestle with how they would fund their treatment plans. Two years on, while most countries in Southern Africa have embarked on some form of treatment programme, Botswana has about 35,000 people in the public and private sector receiving the life-prolonging drugs, funded by the Bill and Melinda Gates Foundation and the Merck Company Foundation. But despite the progress in rolling out the programme, health and government officials are concerned that people still wait until they are very ill before seeking help, making it more difficult and expensive to treat them. On average, HIV-positive Batswana access treatment when their CD4 count is at 80, according to Dr Ernest Darkoh, operations manager for the national ARV programme. Without HIV infection, the normal CD4 count range is 500-1,500. At 200 and below, a patient is at serious risk and treatment should begin. At Princess Marina hospital in the capital, Gaborone, the Infectious Disease Care Clinic lies tucked behind the main hospital buildings. With about 12,000 people enrolled, this is one of the biggest treatment sites in the world. Healthcare workers at the Princess Marina site see over 200 patients a day, many of who are "coming in sick beyond recovery". This has meant that the initiation process, which should take a couple of months to train patients and get them ready to begin taking the drugs, has had to be fast-tracked, Virginia Kebinakgabo, the clinic's sister-in-charge told PlusNews. The workload can be attributed to fear of stigma and discrimination. Many of the patients travel long distances to get here, preferring the relative anonymity of the facility. A patient who had travelled 50 km from Molepolole told PlusNews, "That's my home, I don't want them to see me queuing for ARVs." Consequently, the pharmacy has had to make allowances for patients from outlying villages, who do not always come for their monthly supply of drugs on the scheduled dates. Botswana has all the ingredients for turning the epidemic around: political leadership, optimal use of existing resources, and an established treatment plan. But fear of stigma has proved to be an even bigger hurdle. "People are not yet free to talk about the epidemic. If they can't talk about it, then it will be even harder for them to get help," said Chris Molomo, head of the National AIDS Council. The size of the population also plays a role - in a country of 1.7 million people, only a handful of individuals have gone public about their status. ROUTINE TESTING AS A NEW STRATEGY In January this year, the government introduced a policy of routine testing for HIV as part of its strategy for reducing stigma. Healthcare workers now offer HIV tests in public hospitals and clinics, but patients still have the right to refuse. The change in strategy has been driven by the growing realisation that national plans to provide anti-AIDS medication were likely to fail unless more people knew their status. "It's time to be much more aggressive and normalise it [HIV/AIDS] like any other condition. In a country where almost 40 percent of the population is [estimated to be] HIV positive, and there is therapy available, not offering an HIV test is tantamount to malpractice," Darkoh commented. Both Darkoh and Molomo noted that with most clinics now testing about 90 percent of their patients, routine testing had significantly increased the number of people knowing their HIV status. But human rights activists are concerned that the policy could erode the right of patients to withhold their consent, and that without full knowledge of the procedure and its potential impact, they could be coerced. "The patient is not in charge. This policy does not treat people as right-bearers who can make their own decisions. It's highly unlikely that a patient will be able to tell a doctor that they want to opt out when they want to," Christine Stegling, coordinator of the Botswana Network on Ethics, Law and HIV/AIDS (BONELA), pointed out. According to Stegling, the policy was still a political decision "without any technical backup" and it remained unclear how health facilities were implementing it. The public remained largely uninformed about routine testing and some clinics still did not have access to rapid testing kits. "They are not addressing anything except their technical difficulty of late entry [in the ARV programme] - even then, I'm not sure how this policy is helping," she added. What the government should be addressing is the fact that the country was missing a legislative framework that would make people comfortable with their HIV status, Stegling said. For example, Botswana does not have any policy on HIV/AIDS discrimination in the workplace. Healthcare workers were another problem, she noted, as they projected "their own fears about HIV/AIDS onto the patients". For Stegling, the bottom line is that "at the end of the day, people are scared to get tested, regardless of ARVs". BONELA will soon be conducting research into whether people who had tested HIV-positive subsequently enrolled in the national ARV initiative. Until now, this had been very difficult to measure, Darkoh admitted. For more articles on the subject, plus interviews and a comprehensive database on numbers on treatment in sub-Saharan Africa, visit the PlusNews Web Special