The HIV/AIDS pandemic is still growing inexorably in big parts of the world more than two decades after the syndrome was described and the virus identified.

In Botswana, the history of HIV is also close to 20 years, the first infected person having been identified in 1985. As things go, the virus had probably been circulating in the country in a "silent phase" of the epidemic for a few years prior to the diagnosis of this individual.

What is the actual state of HIV infection in Botswana, and by extension, that of the syndrome? We know from Sentinel Surveillance that infection rates are still estimated at about 37.4% of the adult population, a figure taken to be the highest (or second highest if the latest figures from Swaziland are used) in the world. We also know that the infection rate, according to these surveillance figures, have shown signs of stabilizing, albeit at a very high level, since 2001 but have so far not shown a declining trend. The same appears to be the case in the 15-19 year age group, which is taken to be an indication of the trend of new infections.

This stabilization provokes certain questions; is it a sign that behaviour is changing, and therefore that the campaign against the disease is having an impact, or is it the natural leveling of the epidemic curve of the strain of the virus that is dominant in Botswana? Or is it a combination of the two? The main challenge, of course, is to establish a reversal of the infection rates, essentially to drastically reduce the number of new infections.

While factors such as casual sex, multiple sex partners etc. have driven the epidemic, I do not believe Botswana and other Southern African countries have the worst sexual behaviour in relation to these factors as some would like to suggest. The trends of the epidemic in Southern Africa suggest that there are biological factors in the dominant strain of the virus here, and in the human population, that may also be contributing to the infection trends. Even poverty, which we all believe is an important factor, cannot be the main explanation, as Botswana and other Southern African countries do not by any stretch of the imagination have the highest burden of poverty in Africa or the world. One accepts that the relatively developed rural areas and the high mobility of the populations in Botswana and the other countries are also likely to be other important factors. We, therefore, accept that there are many factors that fuel the epidemic in Southern Africa, that we do not know their relative importance, and that we have to continue studying the epidemic so that we can concentrate our control efforts on the most relevant groups.

An area that needs to be looked at carefully in Botswana is why our society seems to be resistant to change, in relation to sexual behaviour. What are the characteristics of societies that have changed and reversed their epidemics? Why is it that people in Uganda, who are poorer economically than Botswana people, have changed their behaviour positively while our people are changing at a snail's pace? Was the role of the political leadership the critical factor, as most analysts would have us believe, or are there features of Ugandan society that made its people more amenable to change than Botswana society? The epidemic hit Uganda as the country emerged from a decade of political, social and economic turmoil. Did that make the society more open to change? Did the fact that they suffered high death rates before they even knew what it was that was killing them motivate them to change? What about Botswana? Has the sustained period of economic growth proved to be our undoing, making our society complacent, believing in Government doing everything for them? Has that made our people cynical to advice? It is obvious that our behavioural scientists have a big challenge in front of them to look at some of these vexing questions. While people are blaming our leadership for having been quite lukewarm to the epidemic in its early days, they are not explaining why it is that more than five years after a leadership that has given a high profile to HIV/AIDS, behavioural change is still so slow. This despite lessons learnt in the last two decades in HIV/AIDS control in those countries that have been more successful. At a purely technical level, I believe HIV/AIDS control in Botswana has always been up to scratch and compatible with international best practice.

Let me turn to the information available on the state of the epidemic in the country. Looking at the Botswana 2003 Second Generation HIV Surveillance Report. There are certain features that call for more investigation to shed more light on the anatomy of the epidemic in our society. Sentinel surveillance as currently done with regard to HIV follows a method where pregnant women are tested in sentinel sites (selected ante natal clinics) and the findings from these sites are then extrapolated to the rest of the population. The underlying assumption is that the levels of infection among these pregnant women are fairly representative of the levels in the sexually active population from which they come. Then, using a model, this is further extrapolated to the whole population of the country. It is, therefore, critical that the tested pregnant women are at least representative of the pregnant women in the country, and women of child-bearing age.

Taking the 2003 Surveillance Report, there are some characteristics of the study sample that I feel need to be further examined analytically, to check how much representative the sample is of women of child-bearing age in the country. The characteristics that have struck a chord with me are Marital status, Employment status and Occupation.

Let us look at Marital status. According to the Report, the Marital status of the 6 457 pregnant women in the sample was as follows: 6.9% living together; 11.9% married; and 81.2% single. Even while conceding that 74.8% of the sample was aged 29 years and below, this level of marriage appears to be too low for Botswana. I accept that the last four National Population Censuses have shown a continuing decline of women ever married, but if only 11.9% of pregnant women in Botswana are married, this is serious enough to call for further studies. Marriage has an influence on the number of sexual partners, and if this percentage is a valid estimate of the marriage rate of women in Botswana then our society is in serious trouble.

Employment rate is another characteristic of the sample that raised questions in my mind. According to the report, in a sample of 6 487 pregnant women, 20.9% had regular jobs, 3.7% were self-employed, 8.4% had temporary jobs and 67% were unemployed. It would be interesting to compare these figures with the national labour statistics on rates of employment of women? Are they a reasonable estimate of the employment of women in Botswana?

These questions are also applicable to the Occupation status of the 6 384 pregnant women in the sample analyzed for this variable. The Report states that 22% were Domestic workers, 11.2% were Office workers, 8.9% were students and 57.9% belonged to a category described as Others. When one correlates these with the employment figures given in the preceding paragraph, since only 20.9% of the women were reported as having regular jobs, and 22% of the women analyzed for occupation status fell in the category of domestic worker, most of the working women in Botswana are domestic workers! Since 67% were unemployed, the 57% Other category in occupations must be all unemployed!

I am not attempting to be satirical, but I believe these characteristics have to be looked at critically because they are all likely to have influence on the distribution of HIV infection rates. Occupation is a major determinant of social class, and social class has a major influence on HIV infection rates in most countries. Therefore, if our Sentinel Surveillance sample is not truly reflective of the social structure of women in Botswana, it would probably not truly reflect the distribution and level of infection among the women and hence the population of the country.

Marriage is another important variable in the distribution of infection, and the Report itself states that HIV rates were consistently higher among unmarried than married women. It is, therefore, crucial that the sample reflects a good approximation of the level of marriage among Batswana women. If only one woman of child-bearing age out of eight is married in Botswana, then our fight against HIV/AIDS will be that much harder.

I find it difficult to believe this marriage figure, as a Motswana, and the way I know my society. In the same vein, I find it difficult to believe that two out of three women are unemployed, and every woman out of five is a domestic worker. As indicated above, these are characteristics that are likely to have a major influence on the distribution of HIV infection.

Is it possible that the Sentinel Surveillance is missing certain categories of women (of a particular social class or marital status) because of their pattern of health care usage? Do they perhaps use private health facilities, which are not covered by the surveillance?

It is likely that those who conducted this survey took these things into account, but more evidence is needed that the sample used for the surveillance is reasonably representative of women in Botswana, in terms of such characteristics as marriage, employment, occupation and social class, which can influence the patterns of HIV transmission. Some of these gaps in our knowledge should be filled by academic and research institutions. It is an area they can play a very important role in. Information from further studies would also help the response effort against HIV/AIDS, by helping to identify special groups that can be targeted.