UNITED NATIONS--A decade ago, if a person in diamond-rich
Botswana were to die early, it would most likely be from a road
accident or malaria. Today, more than half of the women in
their 20s are expected to die of AIDS.
"We are threatened with extinction," Botswanan President Festus
Mogae, who is in New York for a three-day United Nations
conference on HIV and AIDS, said Tuesday. "People are dying in
chillingly high numbers. It is a crisis of the first
Mogae, who has the dubious distinction of leading the nation
with the world's highest rate of the virus that causes AIDS, is
rallying a response of the highest order. An estimated 38.8% of
Botswana's 1.5 million people are HIV-positive, according to a
U.N. report, making the country the epicenter of the pandemic
in Africa. But it also may be a model for the international
response, as Mogae's government prepares to launch the most
ambitious combination of prevention and treatment programs on
By the end of the year, the government hopes to begin treating
with antiretroviral drugs as many as one-third of those with
"We see before us the most dramatic experiment on the
continent," said Stephen Lewis, a Canadian and the U.N. envoy
to Africa. "If it succeeds, it will give heart to absolutely
every country worldwide."
If the ambitious program could work anywhere in Africa, it
would be Botswana. One of the smallest yet wealthiest countries
in southern Africa, it boasts a well-educated population, a
developed health-care program and, most important, a motivated
president in a region where some leaders still deny the
devastation of acquired immune deficiency syndrome.
Mogae admits that it took him too long to realize the scale of
the crisis. Ignorance about AIDS allowed the disease to get a
foothold, and it was quickly spread by migrating workers and
the breakdown of social taboos that once mandated fidelity.
Now extreme measures are needed to deal with the disease. Since
last year, Botswana has required that all foreign workers be
tested for the human immunodeficiency virus, which causes AIDS,
before entering the country. The government is planning a
house-to-house survey in three towns to determine who needs
care or more education about the disease. It is building
special laboratories to handle wide-scale AIDS testing and is
preparing an infrastructure to deliver drugs donated by
pharmaceutical companies and others.
But along with the hope is the reality that stumbling blocks
can trip up the best intentions.
Even when much-needed drugs are free, it doesn't mean that
everyone can get them. In August, the Bill and Melinda Gates
Foundation and Merck & Co. pledged $50 million each in a joint
project to buy and administer anti-AIDS drugs. But the money
still hasn't arrived, said Mogae, because his government and
the donors have been bogged down in negotiations about
"Our attitude is, you help us do it, you don't do it for us,"
he said. "We will do what you ask, but we need to learn our own
One requirement of the donation is that Botswana be able to
deliver and monitor the use of medicines. The government has
developed a "buddy system," in which two patients work together
to bolster compliance, but it is stuck on the foundation's
demand that Botswana supply clinics with linked computers and
refrigerated storage to ensure that the medicines are handled
"Who is going to pay for it?" Mogae asked. "It hasn't been
decided." In one of the more successful programs, the
government provides free drugs to help prevent mother-to-child
transmission of the disease and baby formula to reduce the
passing of the virus through breast-feeding. Unlike similar
programs in other African countries that limit treatment to the
child, the mother and her partner in Botswana also can receive
"If we can keep the parents alive for another five or six
years, it doubles the chances of survival for the child. It is
difficult to get men to agree to be tested, but we are
beginning to get at them," Mogae said. "We tell them, 'If you
take the medicine faithfully, you can raise your child.' "
However, some women are reluctant to accept canned formula
because its use in villages where breast-feeding is the norm
might reveal that the mothers are HIV-positive.
Sheila Dinotshe Tlou, who has been educating people in Botswana
about AIDS since 1987 and was once called "a prophetess of
doom," said that while previous education campaigns have
targeted women, including men is important.
"We are teaching women to be more assertive--to be able to
demand protection--but at the same time we are teaching men the
basics," she said.
Most of all, it takes a whole community to make prevention and
treatment programs work, especially when it comes to
antiretroviral regimens. At least two pills must be taken daily
without fail. A recent study suggests that missing just five of
100 doses dramatically reduces the drugs' effectiveness.
"I think of the problems we had to convince women to take birth
control pills," Tlou said. "That's one lousy little pill once a
day. I think of how mobile the people are. They are in the
village one day and at the cattle post for a week. If they
forget their hypertension pills, that's one thing. But think of
antiretrovirals. If they don't adhere to the drug schedule,
we'll have rampant drug-resistant viruses running across
"There is not much hope for the 300,000 [between the ages of 15
and 25] who are already infected," she said. "But now I can
meet a 13-year-old girl and tell her, 'Listen to me, sister,
and you will surely live.' "