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Mail and Guardian-Johannesburg
A new dawn for Botswana

January 13, 2003
On August 13 2001 Harriet Kopi weighed 35kg, had severe migraines, a debilitating skin condition and lacked movement in her right side, forcing her to use crutches. Fourteen days later, things had changed.

"My right side began twitching on its own, then it stopped and I found I could move again. That was the last time I used my crutches," Kopi said. "I was skinny, I was weak, still with pain in my head, but now I could walk on my own."

Kopi had begun anti-retroviral therapy. By the end of 2001 her CD4 count - indicating the number of white blood cells to fight off infections - had risen from three to 229.

Kopi has a hectic schedule as the national chairperson for the Coping Centre for People Living with HIV/Aids, an adherence counsellor for anti-retroviral patients and a public speaker. She will take anti-retroviral medication three times a day for the rest of her life.

"I'm keeping very busy," Kopi said. "It's not the end of your life when you find you're [HIV-] positive."

Because of the combined efforts of Botswana's Ministry of Health and private donors, Kopi is one of many people living active lives with the help of anti-retroviral medication.

In January last year the government began Masa, meaning "new dawn" in Setswana. It is the first programme in Africa to offer universal anti-retroviral treatment to the estimated 330 000 people in Botswana living with HIV/Aids out of population of 1,6-million.

But Masa, based on a demand management strategy created by the health ministry and management consulting firm McKinsey & Company, faces a crisis of sustainable human resources over the coming years.

There are about 3 200 patients currently on the programme, and an estimated 110 000 who could benefit from treatment, according to operations manager Ernest Darkoh.

"It's an impressive start to a programme that began at ground zero and had to launch from there," Darkoh said. "When viewed from a backdrop of what needs to be done, however, it's not enough."

In a recent study the African Comprehensive HIV/Aids Partnerships (ACHAP) noted the number of people who could benefit from anti-retroviral therapy would increase more than twofold by 2005, raising the number of needy to about 260 000. This would also mean an increased need for medical staff.

The ACHAP, a joint initiative between the government, the Bill & Melinda Gates Foundation and the Merck Company Foundation, is working with the government to increase staff recruitment and training. Both donors will dedicate $50-million over a five-year period. Pharmaceutical company Merck is donating anti-retroviral medicines. In addition, the Cuban government has committed 100 healthcare providers to work in the country.

Darkoh said every medical professional involved in the programme can double treatment capacity. The difficulty is getting trained staff that will stay on as healthcare providers for the long term in a country that lacks its own medical school.

"We have achieved about 40% of our target for recruiting staff," said Darkoh. "The salaries are just not competitive. Ninety-five percent of our doctors are foreigners."

Although Masa will meet its goal to provide for 19 000 patients in terms of space, drugs, equipment and laboratory testing, the waiting period for treatment could grow from weeks to months without the appropriate number of staff, Darkoh said.

"You could provide treatment under a tree if you had to," he said. "It's follow-up and continuity of care that is the real work."

The Infectious Disease Care Centre (IDCC) in Gaborone is the largest of four anti-retroviral sites in Botswana. The centre provides counselling, antiretrovirals and a place for its lifetime patients to go for check-ups in the Princess Marina Hospital Complex.

People wait on benches and gurneys as nurses work from a desk crammed in the hallway. The centre has six full- time doctors, six part-time doctors and 15 nurses.

"Patients may wait from 5am to 5pm until we can treat them," said Dr Ndwapi Ndwapi, who began work at the centre in April. "We are never in short supply of the drugs we need, but there is already scarce manpower."

Ndwapi said the programme is laying the groundwork for future therapy programmes in Africa. "There is very little to go on as for precedence. We are pioneering here, and we can say we've made a lot of progress."

Although Ndwapi notes that 80% of his patients react positively to antiretroviral therapy, researchers are concerned that the HIV-1C strain particular to this region may resist drugs that have proven successful in Western countries, and that lack of education will make distribution and proper usage of the treatment difficult.

A short walk from the IDCC building stands the Botswana-Harvard HIV Reference Laboratory - Africa's largest and most sophisticated diagnostic laboratory for HIV testing.

Researchers are testing the drug resistance of HIV-1C to evaluate how best to administer anti-retroviral therapy, said Michelle Marian Schaan, health communications officer for the Botswana-Harvard Aids Institute Partnership for HIV Research and Education. The institute has also begun the Kitso Aids Training Programme, a course in HIV/Aids care for Botswana's health professionals.

Another hindrance to providing anti-retroviral therapy is getting word of the treatment to rural areas while combating stigmas surrounding HIV/Aids.

Tuelo Mphele, head of the health education and promotion unit, is responsible for the nationwide effort to combat misinformation concerning anti-retroviral therapy. Her unit aims to inform people of the facts about HIV/Aids, mobilise people for treatment and explain the effects of the medication.

Emma Mwesa, a project coordinator at the Coping Centre for People Living with HIV/Aids, said a great deal of work still has to be done to provide communities with information.

"Many people in Botswana still have no idea what anti-retroviral therapy is or how it can help them. We need to explain to people what is happening, or they will continue to have mixed feelings about going on the programme."

Darkoh said one of Masa's priorities is to increase training at rural clinics. "Since we only have four anti-retroviral sites around the country, people are coming from far locations. We need to optimise our training models so wherever a patient is they can get advice from trained staff concerning their treatment."

Speaking in his sparse office in the IDCC, Ndwapi remained hopeful. "This is not a lost cause, it's a difficult cause. We have crossed an important line and we can't turn back now."