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