Wednesday, June 16, 2004

GABORONE, Botswana — This country’s success in providing the latest medicine to treat AIDS patients in villages of dirt-floor huts hides a darker reality — the deadly disease continues to spread at alarming rates.

“I was embarrassed to [take a visiting dignitary] to a primary school, where there were posters on the classroom wall about using condoms, and the children sang us songs about condom use,” said Tsetsele Fantan, leader of the African Comprehensive HIV/AIDS Partnerships (ACHAP), sponsored by pharmaceutical giant Merck & Co. Inc. and the Bill and Melinda Gates Foundation.

“At that age, they should have been singing about ‘saying no to sex.’ The message should have been about abstinence. We need to focus our message better.”

But even a message directed at those old enough to be sexually active is lost in the din.

“People say they use condoms, but in the bedroom, it is a different thing. And most of the people I know do not stick with one partner. They have multiple partners,” said Emelang Morubisi, a student at the University of Botswana. “Their behavior has not changed. I have not heard anyone say abstinence is the best way.”

“To be seen as a real man, you have to be seen with many partners, have many affairs and bear children with so many women,” said Julia Mocheregwa, also at the University of Botswana, who called such behavior “unacceptable.”

The Merck/Gates ACHAP partnership spends 40 percent of its budget on prevention and has distributed nearly 3.5 million condoms in Botswana since August 2002 through Population Services International.

And studies show that Botswana is the most “condomized” nation in Africa, with more than 85 percent of the sexually active population using them, at least some of the time.

Kgomotso Ntsatsi, who founded and directs the Christian AIDS Intervention Program, preaches abstinence and promotes “True Love Waits” clubs.

But says she needs more financial support to get that message out. She does not oppose condoms, but says they sent an unintended message to Botswana youth.

“Condoms were the first thing people thought of. People never stopped to see if it was working,” Mrs. Ntsatsi said. “It eroded our culture terribly. Condoms brought so much unfaithfulness and so much early pregnancy. Now it looks like everyone is promiscuous.”

She said there is a serious “Sugar Daddy” problem in Botswana, with older men taking advantage of teenage girls to “cleanse” themselves of the AIDS virus. The girls then pass it on to their teenage partners — an observation confirmed by a new report by the United Nations on women and AIDS in Africa.

Incest and rape are not uncommon. Wives and girlfriends cannot say “no” to a man who refuses to wear a condom. Mrs. Ntsatsi said the “stigma” of having contracted a sexually transmitted disease — AIDS was once considered a homosexual disease, in a nation where homosexuality is illegal — continues to plague Botswana.

She said the stigma issue is so bad that people refuse to be tested, and sometimes return to their villages to die, even when they know treatment is available.

She acknowledged that the church in Botswana came to the issue late — in the early days of the epidemic, preferring to condemn rather than to comfort the afflicted — but it is now doing what it can to catch up.

Still, the numbers are daunting — 300,000 with HIV, and after three years, only 80,000 tested and 15,000 enrolled in the antiretroviral therapy program. And more people contracting the virus everyday.

“We have to change behavior,” said Dr. Ndwapi Ndwapi, before starting another day seeing hundreds more patients at the Princess Marina Hospital clinic. “I do not believe Botswanans have a death wish …, but I am afraid there will be many more funerals before people really change their behavior.”

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