May 28, 2003

A model for combating HIV/Aids

Botswana is the first country in Africa to implement widespread distribution of antiretroviral (ARV) drugs through its public health system under a programme aptly named 'Masa' ("new dawn"), a symbol of hope for those living with HIV/AIDS.

The government's year-old programme has the financial support of the African Comprehensive HIV/AIDS Partnership (ACHAP), a public-private partnership with the Bill and Melinda Gates Foundation and the Merck Foundation, as it tackles one of the highest HIV rates in the world.

According to figures provided by ACHAP, approximately 300,000 people in Botswana are HIV-positive, with an estimated 38.5 percent of the 15 to 49 age group infected. As a result, life expectancy will likely drop from 67 to 47 years by 2010, with an adverse impact on productivity gains in this fairly prosperous "middle income" state. A multi-sectoral response to the epidemic has seen a range of policies and infrastructure adopted under the auspices of the National AIDS Coordinating Agency (NACA), that reports directly to the president. The aim is to have no new infections by 2016.

The Masa programme provides free ARVs and counselling at Gaborone, Francistown, Serowe and Maun, targeting four priority groups of HIV-positive people with CD4 (cells that orchestrate the body's immune response) counts of less than 200: pregnant women, children older than six months, TB patients and all adult patients with AIDS-defining illnesses. Dr Ernst Darkoh, ACHAP operations manager of the Masa programme, noted: "The progress is commendable because in one year we have created the single biggest treatment center in the continent." During this calendar year, Darkoh added, the programme would be rolling out to nine additional sites.

The ARV drugs cost the country between US $1,200 and $3,000 a year per patient, with the additional cost of new clinic buildings and equipment escalating the price to between $7,000 and $10,000 a year per patient. The total cost for the first year was $30 million, a report by the Christian Science Monitor said.

Merck has agreed to provide $50 million over five years to help finance the project and has also agreed to "undertake" the provision of free ARVs, according to the Associated Press. The programme is "beginning to make headway" in treating HIV-positive people in the country, reducing HIV prevalence among pregnant women from 36.2 percent in 2001 to 35.4 percent last year.

ACHAP is supporting Masa by managing the recruitment and training of health care workers, infrastructure, drug procurement and storage, establishment of laboratory infrastructure - including a new $3 million research laboratory where young scientists receive training - and implementation of an IT system. The Ministry of Health, with the assistance of ACHAP, implements and manages the ARV programme.

But despite the existence of Masa, people are still reluctant to know their HIV status, undermining government efforts to recommend ARVs to those in need. According to official estimates, 110,000 people are eligible for ARV therapy, but as of this month just under 5,000 were on treatment. "We have to convince people to be tested. Without that happening we cannot reach people who need our services," Darkoh noted. "The main challenge is that people are coming forward very late. People wait until they are deathly ill before they seek aid. It is a lot more resource-intensive to treat people that are sick, and the burden on the health system is much more difficult to manage."

But ARV treatment is not just about distributing pills. "The reality is that if people don't take them consistently they will develop resistant strains to the virus, which will be immune to the systems we have," Darkoh commented. Patients in the Masa programme have 90 percent to 100 percent drug regimen adherence rates - as much as 20 percent higher than in the most successful programmes in Western countries. Doctors attribute this to the intensive counselling given to patients and the effectiveness of the drugs, the Christian Science Monitor reported.

A survey conducted by NACA in 2002 to gauge the success of various initiatives noted encouragingly that general awareness of HIV/AIDS was more than 90 percent. In the 15 to 49 age group, condom use at last act with a non-marital or non-cohabiting partner was 70 percent for women and 77.5 percent for men. However, many people are still ill-informed about AIDS and therefore vulnerable. Only about a third of men and 40 percent of women correctly answered five questions about HIV/AIDS. Nevertheless, Darkoh remains optimistic: "There is no cure for it yet, but I believe there will be." (IRIN)

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