interviewBy Davin O'Regan
New York — The fight against the HIV/Aids epidemic in Africa goes well beyond lab rooms and hospital wards and involves social and political issues at all levels of society, particularly male-female gender relations, said panelists about a recent United Nations Development Programme (UNDP) report on the role of men and HIV/Aids.
Though women in areas of southern Africa are three to six times more likely to become HIV-infected than men, gender-related anti-HIV/Aids efforts need to avoid focusing solely on women, and a holistic "gender mainstreaming" approach is need, the UNDP report said.
Botswana Health Minister Sheila Tlou, who was a panelist at the UNDP event, told AllAfrica about her country's efforts to involve both men and women in Botswana's fight against HIV/Aids.
Could you talk about the distinct roles that men play in HIV prevention and awareness efforts, testing and stigma issues as well as treatment and care?
Men are decision-makers at all societal levels. They're the ones really who determine the health status of their communities and their families. So they are very important when it comes to prevention of HIV/Aids. For example, if it means access to information, it would be very easy for a family to know all about HIV if the male, as the head of the family, decides that the family is going to be involved. That way, all the information, education and communication would be properly transmitted to the family and actually utilized.
Men also determine other behaviors tied to HIV prevention since most of the time they are the ones who seem to be having multiple [sexual] partners and engaging in risky behavior such as excessive alcohol consumption to the point where one might not be able to take safety measures such as the use of condoms.
When it comes to treatment, care and support, men do not participate or rarely participate in care-giving for HIV-positive persons. It's usually women's work. But men are important in care-giving and showing that a person infected with HIV does deserve the love, care and support that we can give as family members. That is where I see a leadership role.
But not only that: access to ARV means we have to test first. Men are important in insuring that their families go for HIV tests. When the male makes the decision that "my partner and I will go for HIV testing," they are more likely to go back to receive the test results and be counseled to make sure that if they are negative, they remain negative. But if they are positive they then can take all measures to ensure that they live longer. That is eating well, practicing safer sex as well as accessing ARVs and other forms of treatment, as available.
You mention care-givers, who tend to be predominantly women. What steps can be taken to involve more men in home-based care-giving?
When it comes to home-based care, Botswana was lucky in the sense that it was something that wasn't started by the government. Home-based care started in communities where groups of people would get together and say "the government has done a lot, but we need to do something. Is there a way that we can as volunteers help families care in the home?" Now these sorts of people were both men and women, because sometimes these groups were formed at the kgotla, which is the traditional village center. When these groups of men and women approached families caring for their HIV-positive members, they showed them that care-givers could be men or women. So that kind of idea spread even among family members, that men should help women.
It has not always been like that. The state and other NGOs also had to intervene to insure that the burden of care doesn't fall just on women and girls, but that men are part of the process. I wouldn't say right now that 50 percent of care-givers are men. But definitely they form a large proportion, I would say 30 to 40 percent. So, care-giving is not seen as solely a women's job.
Men being in the role of leadership and decision-making in various aspects of society, is that a benefit with regards to trying to get men involved and engaged in fighting HIV/Aids?
Yes, it is a plus. At village level, the male, the chief, they are spearheading leadership against HIV/Aids. If the chief -- regarded as the role model for all men in a village -- is able to convince the whole village to work toward preventing HIV, then it is definitely a plus to have men especially those at decision-making levels. Our president [Festus Mogae], the way he has been passionate in the fight against HIV, is definitely something that members of parliaments and ministers have copied.
In your address, you noted the role of legislation in removing discriminating laws and promoting women's empowerment. However, the fight against HIV/Aids has been said to extend from "the bedrooms to the boardrooms." Can laws affect attitudes within the home, or are other steps necessary to change misogynistic attitudes and create a wider belief in gender equality?
I see a wider issue here. In Botswana we have a parliamentary system, and most members are male. They are able to see at the community level what is happening regarding gender relations that will have an impact on HIV and Aids: its spread, its prevention and its treatment. They then bring those ideas as they get them from their people and say, "Here's a problem, how do you think we can solve it?" They introduce these ideas as motions in parliament that are debated after which we can really forge ahead. The issue of amending laws has always risen like this.
Also, women's groups, sometimes in collaboration with the government, have performed studies of laws that discriminate against women. But changing them means bringing communities along. It also means convincing lawmakers in parliament that these laws need to change. This was not as easy as performing the research. It meant changing one law at a time, debating it and really seeing that once it is changed it is for the betterment of the whole community.
We've changed quite a few laws. Employment is one example. Until recently women could not work underground in a mine nor could they work in the Botswana Defense Forces. So women would be disadvantaged vis-a-vis men when it came to economic opportunities. We had to insure that men didn't feel threatened who believed that if women were allowed work underground they would take their jobs. We had to bring men along and debate the law in parliament. It's not easy. It can take quite a while. Sometimes men feel threatened that changes will work against them. You have to show them the benefits to themselves and their families of new laws.
Along the lines of the very successful Miss HIV Stigma Free beauty pageant, what kind of social events have targeted males to raise awareness?
As you know, soccer is a religion in Botswana and other countries. We have something called "Show-UK" which was started by the initiative of the former American ambassador. Show-UK means take yourself and a loved one for HIV testing. When they took it around there would be very few men participating. They set up voluntary counseling and testing centers right on the ground of soccer matches so that people can watch soccer but be able to come out before the match and during the break.
The parliamentary committee on HIV/Aids engaged on a walk - not a sponsored walk - a walk where every stop they made sure that men gathered in the kgotla, a traditional gathering place for decision-makers, and had their HIV-status tests. In the process they got hundreds of people to test, maybe thousands. It was a 200-kilometer journey to the capital city, Gaborone, in which they had to overnight along the way. At each stop people would be tested, including men and chiefs, and then the parliamentarians would continue to the next stop.
Our President [Festus Mogae] is the chairperson of the National Aids Council, which is the highest decision-making board on HIV/Aids. He was able to say that in order to insure that the whole country participates, we need to form sectors. We need to have a financial sector; we need to have the men's sector. So a men's sector was specifically created to have men participate and have their impact felt. It just so happened that the people who decided to spearhead that effort were the uniformed forces, the military and the police. They've been able to reach men since they are really seen as the country's role model. We also have civil society organizations for men like the Society for Men and Aids in Botswana and the "Men, Sex and Aids Project," which actually used to work with UNDP. In this second organization, men were trained in Aids prevention, care and support. It targeted especially young men. From it a lot of organizations have sprung up at the school and community level.
One of Botswana's many anti-HIV/Aids successes has been the high numbers of women who have been accessing the available testing, counseling and care offered at health centers. Has or will this disproportionate response to treatment begin to affect HIV incidence, prevalence and death rates?
Because men are not accessing these services we are finding that even where we are seeing positive results from ARVs, we are seeing them mostly on the women's side. Sixty percent of the people accessing ARVs are women, 15 percent are children. That means only 25 percent are male. Indeed you can see that when you go to hospitals. Male wards are filled with men whereas in female wards there are empty beds.
We are not seeing a rise in the incidence rates of males, but they are dying. It used to be that in rural areas or in villages there could be eight burials a day. These days, you go to a village and there's maybe one funeral a day, often for an octogenarian or a septuagenarian. But if it's a funeral for a young person, it's a male. The death rates of women have definitely gone down, but the male death rates have not gone down that significantly. They are still not accessing treatment for ARVs -- even for treatment of opportunistic infections. For males it can take quite a while to persuade them to get tested.
In response to some questions during the panel, you mentioned that comparisons of HIV incidence rates or prevalence rates don't always offer clear indications the success of anti-HIV/Aids efforts. Do we need new indicators to better describe the effects of policies and the trends in HIV transmission?
I'm hoping that there will be a global attempt to do so. These are things we are discussing now. When we talk about rising prevalence rates, it's not always clear what is happening. HIV is a chronic disease. Rising prevalence rates may worry some people, but really what might be happening is that HIV-positive people are being kept alive. In Botswana, we want people to stay alive so our prevalence rate might go up. People who are on ARV therapy now, we take it that they will be alive in 15 or 20 years time. So, you don't always see prevalence rates going down.
Maybe, then, the best measure should be the incidence rates. But the incidence rate is not easy to get. We estimate that per night so many people are infected with HIV. But it's not easy unless you use other measures. For example, now in Botswana we use the CD-4 cell count levels and try to estimate when likely they became infected.
We really need to come up with better ways of interpreting what any one statistic really means. In a country where there are no ARVs, if you are saying the prevalence rate has gone down it could just be because the HIV-infected died. Is that a good thing? Is it necessarily a good thing when you've lost maybe two million of your people? It's something we really need to talk about. This is something that has been talked about in the Ugandan case. Did the prevalence rate go down in Uganda, or since it was really the first country to be hit so many people died? Maybe the reservoir of infected people disappeared. Some people say there was a behavioral intervention. You can't pinpoint what happened. We can't really tell the full story until we see a rate going down and continuing to go down. But if it ever goes up you wonder whether the numbers of HIV-infected is increasing or more people are receiving treatment.
Recently the government of Botswana instituted new school fees, though primary and secondary education has been free for years and takes up one-quarter of the national budget. Will healthcare outlays, which are about the same proportion of national spending, be facing the same cost-reducing measures?
Each ministry has a mandate to look at cost sharing, mainly because HIV/Aids is taking a large chunk of government money. As a result of our spending on HIV/Aids, a lot of Botswana's development projects have had to stop, for example, schools and hospitals. Right now I need about six primary healthcare hospitals and they have been postponing one national development venture [after] another.
The issue with school fees is minor. The government still pays 95 percent of the cost per student, and the parents pay five percent. There was also a nationwide assessment of who was able to pay. Those who couldn't cover the five percent fee, the child still attends school for free.
The healthcare budget is safe. But we in the healthcare ministry must also find cost-sharing measures. I was thinking about an Aids levy, because Zimbabwe has an Aids levy. We're still looking at ways in which we can at least raise funds to insure that the budget remains unchanged but doesn't impact too much on other development projects. We're looking also at sin tax: alcohol, cigarettes, and perhaps a levy on gas of about one percent. These are just measures we're looking at at the ministerial level, but eventually we'll need to come up with cost-sharing measures.
Right now healthcare is free in Botswana, but if we told people to pay about 20 Pula a week, which is about the equivalent of U.S. $4, there would be an outcry. Some people can't afford that, so we would prefer to raise money in other ways. If we told people to pay for ARVs, adherence to drug regimens would be compromised.
What other healthcare issues are on your ministry's agenda besides the fight against HIV/Aids? There was quite a lot of focus in the Botswanan press recently about the need for organ transplant capabilities after the death of young girl due to kidney failure, correct?
Right now we're looking at non-communicable diseases. We're now facing an epidemic of non-communicable diseases such as cancer, hypertension and diabetes. These are really the diseases of opulence. We're trying with all available means to make sure that those people aren't left behind. Where we can prevent them we should do so. We have instituted national cervical cancer screening at all clinics and hospitals. There was a time when HIV took all our attention, but now as the death rates are going down we feel we can go on to other issues.
[Organ] transplant is one of them, but that is not in our immediate future. We have all sorts of kidney ailments. Some need dialysis, and that's what we're providing. When transplant is necessary, that will have to come after quite a while. We don't even have a law that governs transplants. We need a human tissues act. Actually, with the advent of the medical school, we need a lot of new acts to cover experimentation and study, even cadavers in the medical school.
We'll have to educate people too, because Botswana is very conservative. Right now, the idea of moving a kidney from one person to another has brought quite a lot of difficulties. We'll really need to educate the people.