HIV/AIDS Successes and Challenges

Recently NPR aired a few shows telling about successes Botswana has enjoyed in its fight against HIV/AIDS.  A friend recently heard one of those show titled “Stunning Achievement Against Aids”, and asked me my opinion on it, as someone “on the ground”.  Needless to say, it goes WAY beyond the scope of one little blog post to discuss the entire 25+ year history of the HIV/AIDS pandemic, and the successes and failures along the way.  I do have an opinion though and I will share it here.

The NPR broadcast mentioned several successes including:

• The Government of Botswana providing free Antiretroviral Therapy (ARV) medication and the immediate drop in deaths due to AIDS
• Practically eliminating mother-to-child transmission of HIV with a combination of education and free ARV medication

Credit was given to former President Festus Mogae for much of this.  President Mogae was a great president whose excellent leadership has ensured the continued stability and prosperity of Botswana in the face of the HIV/AIDS pandemic which threatened the future of his country.  In a time when African leaders were more often poor leaders, dictators and tyrants such as Robert Mugabe of Zimbabwe — Festus Mogae stands apart.

Certainly President Mogae gets credit for making the HIV/AIDS pandemic one of the country’s highest priorities, and for using his office to advocate for testing and behavior change to stop the spread of the virus.  He also gets credit for getting Botswana to use some of the wealth from their diamond reserves to help pay for the ARV drugs; and for providing access to the ARV drugs for all the Botswana citizens who need them.  President Mogae also lobbied the US for the return of the Peace Corps to Botswana to help with the crisis — this is why I am here today.

Credit for this achievement is not his alone, however.  It is shared by the drug companies in the United States who developed the ARV drugs; and also by George Bush’s initiative, the President’s Emergency Plan For AIDS Relief (PEPFAR).  PEPFAR provides tens of millions of US tax dollars each year to be spent on ARV drugs taken by citizens of Botswana.  If there had been no ARV drugs, and no money to buy them, people in Botswana (and the rest of the world) would still be attending funerals at an alarming rate, and all babies born to infected mothers would have the disease as well.

HIV used to be a death sentence.  The ARV drugs have changed that.    People still die of AIDS here but it is not so common.  These days it happens when someone does not take their medication or does not do it correctly and they get a resistant strain of the disease.  It also happens when someone does not get tested and the virus has progressed to the point that their CD4 count gets so low that an opportunistic infection kills them.  However, the shockingly large number of deaths has been stopped.  You can’t argue that saving lives is not a stunning achievement — but what now?  Botswana still has the 2^nd highest prevalence rate in the world.  About 25% of the population are HIV positive.  Those with the virus take their free AVR medication and continue with their lives, and often continue to spread the disease.  There is still stigma associated with the disease so it is often their little secret.

The AVR medication has saved many lives, and in addition it has helped to lower the spread of the disease.  If someone who is HIV positive has unprotected sex, if they are taking their AVR drugs correctly the virus is at undectable levels, and so it is less likely that they will spread the disease.

Those who do know someone who is infected and on AVR drugs see someone who doesn’t look sick, that person is going to work every day, attending church, participating in sports, they don’t seem to have any problems.  The urgency about HIV/AIDS seems to be fading.  Now it is often looked at as no worse than any other chronic disease that can be managed such as diabetes.

The Batswana are not doing the things they need to do to stop the spread of the virus.  I suspect the lack of motivation is because the immediate threat of death is not hanging over their heads anymore.  They need to be doing the following things…

• Being faithful and stopping the practice of Multiple Concurrent Partnerships (MCP)
• Getting circumcised (Male circumcision reduces the risk of contracting the virus)
• Reducing alcohol abuse (we all know bad decisions are made when drunk)
• Reducing inter-generational sex and transactional sex
• Practicing safe sex (condom use)
• Routine testing

As Peace Corps Volunteers we are trying to bring about behavior change in a country whose people have been overly saturated with the message, and who continue to spread the virus.  All Peace Corps volunteers in Botswana today are here to help those infected or affected by the disease.  Whether the volunteer works in an NGO for orphans and vulnerable kids (as Tish does); or works in a District Aids Coordinator office trying to build their capacity (as I do); whether they work in a school teaching life skills; or are based in a clinic helping with testing and dispensing medications – it is all about HIV/AIDS.  This is what President Mogae requested when he invited the Peace Corps back into Botswana.

Behavior change is not easy, just ask someone who quit smoking.  Also, much of the behaviors that need to be changed have to do with sex which is a subject many are shy about even discussing.  Some of the sexual practices that should be changed are part of the culture.  MCP for example, is pervasive.  I personally know Motswana men who have been to the same events and workshops I have been to where the subject of MCP is explained, yet who have one or two women “on the side”.  It is not just the men; the women are guilty as well.

I once asked my co-worker why MCP is practiced here in what is nominally a “Christian” nation.  She smiled and replied, “Aish!  Rapula, I have seen where a fight broke out in the congregation between two women who were both sleeping with the minister.”  I had to laugh, but if the community leaders are openly doing this how can the message that this behavior is too risky be taught.

One of the bits of advice that used to be given to young women on the eve of their wedding, by their “aunties”, was that a wife should never ask what their husbands were doing when they were away overnight.  There are several Setswana sayings that reveal a lot about their culture.  One such saying, “Monna ke selepe o a adimanwa”, loosely translated means, “A man is just like a sharp axe, he should be shared”.  Another saying is  “Monna ke poo”, which means “A man is a bull”; meaning that a man is like a bull and should service all of the “cows” in his corral.  These practices are not overt now, but continue secretly.  MCP is deeply ingrained in the culture of Botswana.

Another thing that troubles me is that many people who are supposed to be on the front lines in this battle, don’t really see it as a huge problem.  My own District Aids Coordinator and Assistant District Aids Coordinator do not believe Botswana has the second highest prevalence rate in the world, even though those are the statistics accepted by the Botswana Ministry of Government and by the rest of the world.  They just don’t believe it.  They dismiss the data as being incorrect.

Often, when Peace Corps Volunteers are together we discuss our jobs, our successes and our challenges.  Invariably someone will ask, “Do you think we really should be here?”  A large number of volunteers will answer in the negative.  Sometimes we feel we are preaching a message that is falling on deaf ears.

Most Peace Corps volunteers here get the most “job satisfaction” from their secondary projects.  The primary project (HIV/AIDS related work) is something we do without seeing much effect.