- The Washington Times - Wednesday, June 16, 2004

GABORONE, Botswana — Every morning before dawn, they begin lining up at the Princess Marina Hospital clinic, many having traveled for hours from remote villages.

By the time Dr. Ndwapi Ndwapi arrives, the green waiting room is jammed with bodies and fetid with illness, antiseptic, human breath and sweat, as overcrowded as a motor-vehicles office in the United States but eerily quiet and orderly.

By day’s end, another 250 AIDS patients will have been seen by Dr. Ndwapi or his two colleagues, had their blood sampled and their CD4 count and viral load re-determined, given another month’s prescription for life-saving antiretroviral (ARV) drugs and sent on their way. Many return to their one-room huts with thatched roofs and dirt floors, carrying another month’s supply of the world’s most sophisticated pharmaceutical technology.

“I go to a funeral every other week. It is either a friend or a relative. I don’t have a choice. I have to be here,” said Dr. Ndwapi after a long day in the clinic.

“Before we were doing this, we were doing nothing. … I hope, I believe what we are doing here is a model for all of Africa.”

Dr. Ndwapi, who spent 11 years in the United States studying at George Washington University and the Medical College of Pennsylvania Hospital, returned to Botswana to participate in his country’s full-scale assault on HIV/AIDS. He and his colleagues, several of whom also studied at George Washington, are passionate, obsessive and driven — working 12- to 14-hour days — by the need to do more, to test more people, to get more of them on ARV therapy and to teach more nurses in order to save their dying country and continent.

“Most of the patients I see, when they come in, are at death’s door with CD4 counts of less than 100,” he said, noting that 800 is considered healthy. CD is a measurement of the strength of a person’s immunity system.

“All of a sudden, they have three or four miracle pills, and they get better. They put on weight. This is a manageable disease. I ask myself everyday how we can get 100,000 people on therapy.”

In 2001, Botswanan President Festus Mogae, an Oxford-educated economist with experience in Washington at the International Monetary Fund, went before his parliament and announced that he planned to make life-saving ARV therapy available to every Batswana in need. The nation’s survival was at stake.

“I’m a development economist by training, with an emphasis on public health care,” the president said in his office.

“We were building rural clinics all over, we were fighting childhood diseases and attaining favorable vaccination rates. Maternal morbidity and infant mortality were declining and life expectancy was increasing to 65, 67 years,” he said.

“And then it began to stall … and everywhere we looked, we saw the impact of AIDS. It was killing our trained people — the nurses, teachers, engineers — the very people we need to fight this disease.”

The average life expectancy in Botswana now is about 45 years old and is expected to drop as low as 35.

And while the rest of Africa — where about 45 million people carry the human immunodeficiency virus (HIV) — dithered, Botswana got down to providing its developing-world population with the most sophisticated medical help on earth.

“President Mogae gets it. He understands the problem and what needs to be done,” said Dr. Dan Baxter of the University of Pennsylvania Medical School, who is in Botswana for two years to train local doctors and nurses in administering ARV therapy.

“Every day, we are saving lives, reducing stigma and the fear of being tested, and providing hope,” Dr. Baxter said. “The government of Botswana will go down in history as one of the most enlightened, willing to take a risk at helping its people. Botswana is a beacon for the rest of Africa.”

Botswana is a landlocked desert country, best known in the United States for the 1980 film “The Gods Must Be Crazy” and more recently for Precious Ramotswe and the “No. 1 Ladies Detective Agency” mystery novel series, set in Gaborone, the capital.

In public health circles, the nation of 1.6 million people has the distinction of having about 300,000 people infected with HIV — nearly one-third of the adult population and by some measures the highest rate in the world — where someone dies of AIDS every 10 minutes.

Unlike much of the rest of Africa, Botswana is democratic, politically stable and relatively wealthy, and its economy, bolstered by 30 percent of the world’s diamonds, is market-oriented and growing. Botswana has very friendly relations with the United States and even pays the U.S. government to send U.S. Peace Corps volunteers.

At about the same time that Mr. Mogae committed his government to fighting the AIDS epidemic, the Merck Pharmaceutical giant, publicly vilified for years by Doctors Without Borders and AIDS activists for withholding cheap ARV drugs from the world’s poor, was casting about for a place to concentrate its charity and technical and business expertise where it might make a difference.

Merck pledged $50 million and free drugs over five years, and it solicited and got another $50 million from the Bill and Melinda Gates Foundation. The plan was to apply a Merck/Gates business model — plans, goals and accountability — to a problem that seemed intractable.

“In July 2000 at the Durban AIDS conferences, everyone kept saying ‘We haven’t got enough money. We haven’t got enough money,’” said Debbie Stanford — a Motswana, or a citizen of Botswana, and manager at the African Comprehensive HIV/AIDS Partnerships (ACHAP), the partnership between the Botswana government, Merck and the Gates Foundation.

“Merck said, ‘Let’s find a country with an AIDS problem and take the money issue out of it — give the money and the drugs for free.’”

This year, the government of Botswana has budgeted $100 million, about 90 percent of the total cost, to buy drugs, and fund clinics and testing centers throughout its borders.

Merck and Gates recruit and hire managers and doctors and lend them to the government. ACHAP also provides seed money for numerous organizations, including Christian abstinence programs, day care centers for AIDS orphans, and umbrella organizations to prevent the duplication of services.

The public-private partnership has attracted worldwide attention, and others have jumped on board — Harvard University, Baylor University, Bristol-Myers Squibb, the Centers For Disease Control and Prevention (CDC), the United Nations and an alphabet soup of acronyms and nongovernmental agencies — all in search of one place in Africa that the public-health community can call a success in the battle against AIDS.

“If it can’t work in Botswana, it can’t work anywhere in Africa,” said Dr. Ernest Darkoh, director of the ARV therapy program in Botswana.

Since the first site opened in January 2002, about 80,000 Batswana have been tested, with 21,000 testing positive for HIV and being registered in the government program. Twenty-three sites will be running by the end of this year.

About 15,000 Batswana have become sick enough to go on ARV therapy — several pills twice a day, morning and night.

Mr. Mogae calls this figure disappointing.

“We’d hoped to be up to 60,000 by now,” he explained.

Others consider it a remarkable success in the history of a disease that has defeated one failed therapy program after another.

“I was very sick, having terrible headaches. I was almost dead,” said Kglalelo Ntsepe, 33, during lunch at one of Gaborone’s gleaming shopping malls. “Now I think I will die when I am old. I won’t be killed by AIDS, because our government is supporting us. I want to thank the president for saving my life.”

Miss Ntsepe, whose weight has doubled and now looks healthy enough to compete in a triathlon, has been on the “first line” ARV therapy for two years. She takes one pill every morning and four every night.

Thabang Isaacs, 5, got HIV from his mother at birth. He was been on ARV therapy since November. His mother spent the entire day — up at 4 a.m., back home at 8 p.m. — traveling to Gaborone to renew his prescription.

“He was very, very weak. Before he was just bones sitting there. Now there is somebody in him,” said Brenda Fonteyn, who runs the Dula Sentle center for 75 AIDS orphans in Otse, a village 20 miles outside Gaborone with a population of 3,000.

In 2001, Andrew Natsios, an administrator for the U.S. Agency for International Development, said many Africans have “never seen a clock or a watch their entire lives” and cannot be expected to take their drugs on time.

But Dr. Ndwapi said that there is a 90 percent “adherence rate” and that his patients take their medicines religiously. This is a better adherence rate than found at many U.S. clinics and reduces the chances of therapy failure and drug resistance.

Dr. Ndwapi said that so far, only 6 percent of his patients have “failed” and had to move to second-line therapy. There is little that can be done for a patient who does not respond to the three lines of therapy available.

Although some patients in the United States, like Magic Johnson, have been doing well on these therapies for years, others succumb to the disease. A recent study in Brazil, which like Botswana offers free ARV therapy to its citizens, showed that after two years, 44 percent had failed the first line and were on the second line of treatment.

“Ten percent don’t respond. Ten percent drop out. Ten percent die. In three or four years, the third line fails,” said Dr. Richard Marlink of the Botswana-Harvard Partnership.

“I do not know what will happen to this patient tomorrow, but I do know he won’t die on my watch today. If you take these drugs, they work. They buy us time. They are the best available choice,” Dr. Marlink explained.

Dr. Peter Kilmarx, who heads the CDC-funded HIV/AIDS testing program in Botswana, said he takes one day a week to practice medicine and dispense ARV therapy at one of the clinics, because he gets a “contact high” from his interaction with patients, who literally get up and walk after a few weeks on ARVs.

“Botswana is the ‘proof of concept’ country,” Dr. Kilmarx said. “If we can show success here, there is hope we can show success in other countries. What we learned here is the importance of leadership. That is the main thing that can and should be replicated.”

However, even with committed leadership and a generous budget, the Botswana experiment also exposes serious gaps and shows that the best may not be enough to hold back a rising wave of AIDS illness, which is likely to crash over this nation and much of Africa in the next 20 years.

“Inevitably, we have to mobilize to handle a huge failure population. Even if it is 15 percent or 20 percent, it is still a huge number of people,” Dr. Ndwapi said. “We are already above capacity. We have to prepare for a soft landing, prepare to pounce on this problem. However, I think it is going to get worse before it gets better.”

“We have to change behavior,” said Dr. Ndwapi, before starting another day of seeing hundreds more patients. “I do not believe Batswana have a death wish …, but I am afraid there will be a lot more funerals before people really change their behavior.”

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