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Susman, Ed

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Botswana gears up to treat HIV patients in Africa's largest program

The attempt to bring treatment services to the HIV-ravaged people of Botswana faces a critical challenge: to train enough people to deliver antiretroviral medication to more than 120 000 people who need treatment, before the disease affects the very people required to administer the drugs. ‘‘We need to get people into treatment and prevention programs before the epidemic eats away at our human resources,’’ said Banu Khan, MD, the national coordinator of the National AIDS Coordinating Agency of the Government of Botswana. ‘‘We are scaling up programs in our public–private partnership. We see antiretroviral treatment as a preventative tool. The availability of treatment is breaking down the stigma associated with AIDS. Access to treatment leads to testing and to prevention.’'

In Botswana, 35.4% of pregnant women are HIV positive. Dr. Khan said that the level of infection appears to be reaching a plateau, although at a very high level.


The unique Botswana program to attempt to treat all its patients with antiretroviral combination therapies involves donations of time and money from the Bill and Melinda Gates Foundation, the Merck Company Foundation and the Government of Botswana. Each group is spending $50 million over the next 5 years to get treatment programs up and running in the country, which has the highest HIV/AIDS prevalence rate in the world – an estimated 39% of its adult population. ‘‘We are now treating 12 000 people,’’ said Thendani Gaolathe, MD, co-director of the Infectious Disease Care Clinic, Princess Marina Hospital, Gaborone. ‘‘We expect to have 15 000 people under treatment by the end of 2003 and we expect to add another 10 000 patients to treatment programs by the end of 2004.’’ Currently, the patients are getting treatment at five centers in Botswana, but Dr. Gaolathe said that another 12 centers are expected to be opened by the end of 2003. ‘‘Now that we have other options available, people are coming to screening programs,’’ Dr. Goalathe said. ‘‘In addition, we are seeing 85 percent adherence to treatment regimens.’’ In a press briefing on the program in Botswana, Donald de Korte, MD, Botswana-based project leader for the African Comprehensive HIV/AIDS Partnerships (ACHAP), said, ‘‘We are starting to see signs that the program is saving lives. We are in the process of training 1500 health care workers to extend the program.’'

Killing myths

The early success in Botswana appears to refute numerous myths that have arisen over why bringing antiretroviral therapy to Africa and other Third World nations is difficult or not impossible. Those myths were attacked by Jean-Paul Moatti, PhD, professor of economics at the University of the Mediterranean, Marseilles, France, in the keynote address at the Second International AIDS Society Conference on HIV Pathogenesis and Treatment in Paris, France. ‘‘Access to antiretroviral therapy is not just a moral imperative,’’ Moatti said, ‘‘it is good economic sense.’’ The economics are remarkably simple: HAART prevents the opportunistic infections – the pneumonias, dysenteries, skin eruptions and oral growths that require people to be hospitalized. Hospitalization is the most costly of medical interventions, so by treating people with proper medication, expensive trips to the hospitals are reduced. A corollary to reducing hospitalization, he noted, is reducing the costs of the drugs used to treat the opportunistic infections.

Rationale for treatment

`‘We have an economic rationale now to deliver drugs to these people,’’ said Dr. Michel Kazatchkine, director of the Agence Nationale de Reserches sur le SIDA, the Paris-based French national AIDS research organization. ‘‘Three years ago people were still thinking we should go to prevention rather than treatment. Then people were saying the drugs are too expensive. Then people were saying drugs were not cost-effective. Then people were saying we don't know if the drugs will be effective in the context of the developing world.’’ ‘‘At this conference,’’ Kazatchkine said, ‘‘we believe we are bringing evidence to fight against all of these arguments.’’ One myth was the fear of noncompliance and the subsequent growth of more dangerous and resistant virus. The Botswana experience – with 85% adherence – crushes that myth. Dr. Moatti said that another myth – that treatment programs would undermine prevention programs – has also been shown to be inaccurate. He said his research shows that if people are tested and their HIV status is determined then these people tend to increase their use of condoms to prevent infecting a partner. If drugs are not available, he explained, there is no reason for patients to get tested.

Complimentary programs

`‘There is now clear evidence in the HIV/AIDS field that suggest that prevention and treatment are indeed complementary,’’ he said. In fact in Botswana that is exactly what Dr. Goalathe and Dr. Khan reported. Moatti also said that another cruel myth tried to make a case that as bad the epidemic is, the overall impact on society is really not that great. He said that assumption is wrong. At its present pace, within four generations the economy of South Africa will be halved by AIDS, Moatti said, citing new figures developed by economists at the World Bank. ‘‘We now realize that the social loss for economic development related to AIDS has been significantly underestimated and that the potential economic benefits of antiretroviral therapy have been consequently underestimated,’’ he said.

More than money

Added Joep Lange, MD, the immediate past president of the International AIDS Society, ‘‘All the money that has been pledged to fight AIDS in the underdeveloped world is not going to solve all the problems alone.’’ There is also an implementation gap. But it is important that we are going to dispel the economic myths which are known to be a barrier to care.’’ ‘‘Another bright sign,’’ said Peter Zeitz, DO, executive director of the Global AIDS Alliance, based in Washington, DC, ‘‘is that we have seen a sea change in attitudes among the political leadership in Africa. In Botswana, in Uganda and in more than a dozen nations in Africa, political leaders are now talking about the AIDS epidemic as a national emergency.’’ Now, the political will and international aid to do something about it have to be scaled up as well, Dr. Zeitz said.

Websites African Comprehensive HIV/AIDS Partnerships (ACHAP): Global AIDS Alliance: Bill and Melinda Gates Foundation: Government of Botswana:

© 2004 Lippincott Williams & Wilkins, Inc.