Inconceivable as such willful ignorance may be to outsiders, it’s still common in Botswana, the country with the world’s highest rate of AIDS–nearly 40 percent among adults. That’s a big reason Africa’s most comprehensive assault on the AIDS pandemic is falling short. Two years ago, small but wealthy Botswana was to be Africa’s paradigm for facing up to the scourge. Instead, the country’s program now serves chiefly as a cautionary example to the United Nations and the U.S. and South African governments, which are committed to putting masses of African AIDS victims on lifesaving drugs.
There’s no dispute that the program is disappointing. When President Festus Mogae announced free antiretroviral therapy in June 2001 for all who needed it, the government hoped to begin treating as many as one third of those with AIDS by the end of that year. But so far only about 9,000 people are on drug therapy–27 percent of the 330,000 believed to carry the disease. A further 20,000 people are believed to need the drugs now.
Experts are still searching for explanations, but it seems clear that Botswana officials made some bad assumptions. Namely, they thought that people would be motivated to learn their HIV status once lifesaving drugs were available free of charge. Testing was also seen as a key to changing behavior. Through the Centers for Disease Control, Washington funded a network of 16 “voluntary testing and counseling” centers in Botswana. Mogae and other officials took HIV tests, and ubiquitous billboards and broadcast advertising hammered home the “know your status” message. Yet in three years fewer than 65,000 people have taken the test. Many people say they couldn’t live with the knowledge that they carry the virus. Testing centers are steadily getting busier, but not enough to keep up with the rate of infection.
Now experts are reaching for new strategies. In November U.S. Ambassador Joseph Huggins launched the “show you care” plan, which urges those who have already been tested to bring others into the centers. President Mogae has blamed a dearth of medical workers for the shortfall in results. Next year, he announced, government health facilities will begin routinely checking all patients for AIDS. To some experts, the plan seems tantamount to mandatory testing, a human-rights abuse; it may discourage patients from attending the clinics altogether.
Some experts advocate more radical moves. In Francistown, health-care workers note that the rate of sexually transmitted diseases–and presumably AIDS infections–surges over public holidays. “We need to ban beer for five years,” says Kennedy Fungwane, 53, a local AIDS counselor. “Maybe then people would change their attitudes and would face the truth.”
Botswana may yet find ways to get ahead of the infection curve, but it’s not a given. Its difficulties stand in sharp contrast to the hugely ambitious new treatment plans going forward elsewhere. South Africa, which approved a new plan last month, predicts that nearly a million AIDS patients will be on the lifesaving drugs within four to five years. The country’s well- organized lobby comprising people living with AIDS, the Treatment Action Campaign, is expected to play a key role in getting people on the drugs–a factor missing in Botswana. The World Health Organization plans to use trained medical workers to provide antiretroviral drugs to 3 million people by 2005–10 times the number now receiving the drugs. Botswana’s experience, though, argues that all this will be harder than it sounds.
