- The Washington Times - Thursday, June 27, 2002

GABORONE, Botswana An epidemic of AIDS that afflicts more than a third of the population of this southern African country threatens to undermine one of the continent's most democratic and best educated countries.

"AIDS is the main topic of conversation in Botswana," said Edmund Dladla, national coordinator of the Botswana Network of People Living with HIV/AIDS. HIV is short for Human Immunodeficiency Virus, which causes AIDS and is transmitted via the bodily fluids of an infected person.

"It has reached the point where people here wonder whether someone they have just met might be HIV-positive, and if so, whether that person has 'disclosed' their status, whether they have had a test, whether they practice safe sex," Mr. Dladla said.

"Anyone who is of working age or who has some education talks about it. And they all wonder about the impact it is having not only on those close to them, but also on the country as a whole. People are scared."

The AIDS Institute at Harvard University says Botswana has the world's highest incidence of the disease. It has opened in Botswana the largest AIDS laboratory in Africa and set up trials for a vaccine to combat HIV-1C, the African strain of the virus that causes the disease.

An article in the weekly Harvard University Gazette, extensively quoting AIDS Institute Chairman Max Essex after his return from seven months in Botswana, said the incidence of AIDS among adults there is 36 percent to 38 percent. But among women most likely to become pregnant those 25 to 30 years old about 50 percent are infected.

The AIDS Institute has been collaborating with the Botswana Ministry of Health on AIDS research for the past five years. Dr. Essex is the author of the comprehensive reference work "AIDS in Africa," first published in 1994; a second edition is being published before next month's International AIDS Conference in Barcelona.

Dr. Essex contradicts much of the thinking that ascribes the AIDS epidemic in Africa to societal factors such as breakdown of the social structure, government instability, war and poverty, lack of education about "safe sex" or scarcity of condoms. None of these factors is at work in Botswana, among Africa's most stable, affluent and well-educated countries, he said.

He was quoted as saying he suspects that HIV-1C the virus prevalent in Africa, where it is spread through heterosexual sex may be more virulent and easier to spread than HIV-1B, the prevalent form in North America and Europe, on which most AIDS research is focused. This increases the importance of studying and devising treatments against the African form, he said.

For a country roughly the size of Texas, Botswana has a relatively small population of 1.6 million. In Gaborone, the capital, the incidence of AIDS among those ages 15 to 49 is 44 percent. For the country as a whole, the average life expectancy is projected to decline from 64 years in 1998 to 42 years in 2010. Health authorities expect infant mortality to increase from 41 to 65 per 1,000 births because of AIDS.

Banu Khan, a doctor who heads the National AIDS Coordination Agency, said the crisis is expected to cause a 20 percent decline in the national budget because of increased spending and reduced income.

"For our people, it means a further loss of income, increased health care expenditure, reduced farming output and reduced revenues," she said. "It is due in part to a large population of mobile workers, especially in the mining industry, combined with poverty and unemployment."

Botswana enjoys a remarkable economic growth rate of 7 percent, but specialists expect the loss of young adults to AIDS will reduce economic growth by the year 2010 by a third more than otherwise would be expected, Dr. Khan said.

"We are the most hideously affected country in the world," President Festus Mogae said in his latest broadcast to the nation urging people to come forward for free medical testing and lifetime supplies of drugs to those infected. "The pandemic is not abating," he lamented.

Last summer, when the United Nations held its first General Assembly meeting devoted solely to AIDS, Mr. Mogae told world leaders in New York: "We are threatened with extinction. People are dying in chillingly high numbers. It is a crisis of first magnitude."

But so great is the stigma that few people willingly acknowledge they are afflicted.

Skimming the death notices of the local Botswana Gazette shows a disproportionate number of young or middle-aged people succumbing to diseases associated with AIDS, such as tuberculosis or pneumonia. AIDS is simply not mentioned, and the precise toll it has taken is difficult to calculate.

"There is hardly anyone around here who does not know someone who has died of AIDS or who is HIV-positive," said Mr. Dladla, the Living with HIV/AIDS coordinator. "Compare that with the United States or Europe, and you get a measure of its impact."

Why should one of the most democratic, wealthiest, best educated and least corrupt nations in Africa be cursed with such a scourge? How can it be stopped?

Answers to such questions are sought by the Botswana government, which embarked this year on an intensive five-year program and has been joined by private-sector groups in the United States.

The Gates Foundation has provided $50 million to help strengthen the primary health care system, while drug manufacturer Merck is matching that contribution with anti-retroviral (ARV) medicines. Another $50 million is coming from Bristol-Myers Squibb, Unilever and the Harvard AIDS Institute, which are working closely on care models designed by the government and the World Health Organization.

An estimated 19,000 people are enrolled in their first year of ARV treatment under a program in which people who need the drugs will get them for life. The Ministry of Health has calculated the cost of the drugs, treatment and counseling at about $600 per person per year.

Testing and monitoring of Botswana's AIDS plague is carried out by the new Botswana-Harvard Reference Laboratory at Gaborone's Princess Marina hospital. The first of its kind in Africa, the laboratory, with a staff of 50, is equipped with gene sequencers and blood-cell sorters, enabling medical scientists to keep track of the virus' spread, particularly that of HIV-1C strain.

Dr. Essex, head of the Harvard AIDS Institute, said while helping set up the laboratory that the HIV-1C strain requires its own medicine because "no one knows if a vaccine against HIV-1B will work as well against HIV-1C."

Health officials are concerned that strains like HIV-1C may become more drug resistant if, as happened with penicillin in the mid-20th century, sufferers stop their medications as soon as they feel better.

In a small country like Botswana that does not have a medical school, most of the doctors are foreign, and many stay for only short periods.

"The program we have put in place here can work in other African countries, and with international financial help, it can be sustained," said Clement Chela, a London-trained doctor on the staff of the National AIDS Coordination Agency.

The only country in Africa that appears to have curbed the spread of the disease so far is Uganda. Botswana has taken a cue from that distant country by emphasizing prevention using radio and television broadcasts, billboards, advertisements and trained counselors.

Much of the campaign in Botswana has been financed by the country's diamond industry.

Three years ago, the nation's biggest employer the Debswana diamond mining company, whose annual revenues of $1.8 billion amount to nearly half the national income found after testing its work force of 6,000 employees that just more than a third of those between ages 24 and 40 were HIV-positive.

"We realized we had to do something fast, because diamonds are the foundation of our economy," said Tsetsele Fantan, director of the company's HIV/AIDS program. Many of the employees were found to be polygamous and to be supporting many children, she said.

The company agreed with the government that it would provide free treatment for each infected employee and one legal spouse, while the government would provide treatment for other partners of such employees and their children. The government also has insisted that major banks, transport companies and even fuel stations provide better levels of health care and make HIV counseling available to employees.

"It is extraordinary how things have changed," said Mr. Dladla, the HIV/AIDS network coordinator.

Mr. Dladla, a science teacher commissioned by WHO to prepare a paper on the stigma and its effect in Botswana, added: "For a decade, until the end of the 1990s, we were in a state of denial, blaming the crisis on foreigners. Then, as we realized the extent of the crisis, we started acting. Today, I would say the government is very transparent, proactive and accountable. We are the most advanced African nation in this struggle, and believe me, I would not have said that just three years ago."

The government has set up four HIV/AIDS centers at hospitals in Gaborone and three other communities.

U.N. health officials said that if Botswana with a per capita income of $3,600 a year, calculated by the World Bank to be seven times higher than the figures of its neighbors cannot manage to curb its AIDS crisis, then no other African nation can.

"We have found that Botswana can afford to sustain this scheme, even though the drugs are needed for life," said Catherine Sozi, a British-trained Ugandan doctor working for the U.N. AIDS program. "Community and the patient perception of AIDS or the role of ARVs are still not very well understood, and many have little comprehension of the complexity of starting lifelong anti-retroviral treatment."

Dr. Sozi has no illusions that Botswana faces a struggle in reaching its goal of stopping new infections by the year 2016 the 50th anniversary of independence from Britain.

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