Washington, DC — Botswana has the highest prevalence of HIV infection in the world at around 35%. Mogae's leadership on this issue has been widely praised, not least because his government has committed itself to offering treatment to all those who need it, a commitment that could see 100,000 people being given anti-retroviral drugs, ten times more than the number currently being treated. Attracted by the possibilities of working effectively in an atmosphere of political commitment, international foundations, pharmaceutical companies and multilateral bodies have entered partnerships in Botswana to support the scaling up of the country's health facilities and capacities: Dr Helene Gayle, head of HIV at the Bill & Melinda Gates Foundation says Botswana should be a model to the rest of the world of how to mount a comprehensive programme incorporating both prevention and treatment. At a conference on November 12, 2003, in Washington, DC, on 'Botswana's strategy to fight HIV/Aids - Lessons for Africa, Bush' organised by the Center for Strategic and International Studies, the President of Botswana, Festus Mogae set out his assessment of the HIV/Aids crisis in his country. The transcript was provided by the Kaiser Family Foundation.
Mr. Moderator, Program and Executive Director of the CSIS Task Force on HIV/AIDS, Your Excellencies, members of the diplomatic corps, senior officials of the United States Government and of the Botswana government, distinguished representatives of our partner organizations in our fight against HIV, distinguished ladies and gentlemen; I welcome this opportunity to address this important international conference on Botswanas efforts to combat HIV/AIDS that has been kindly hosted by the United States Center for Strategic and International Studies and funded by the Gates Foundation.
As partners, as honorable Senators have said, we should regularly interact with each other at both political, managerial and operational levels. I should also take this opportunity to congratulate Ambassador Randall Tobias on his recent appointment as a United States Global AIDS Coordinator. With his distinguished career in the private sector Ambassador Tobias is particularly well-placed for this leadership role. My government and I look forward to working in close collaboration with him.
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I am particularly pleased that Ambassador Tobias visited Botswana in early October and was able to make an on the spot assessment of our HIV/AIDS programs. As many of you are aware Botswana is the most severely affected country by the HIV/AIDS pandemic. And we have the unfortunate distinction of having one of the highest HIV/AIDS set of prevalence rates in the general population globally. The 2002 sentinel surveillance studies estimated that we have an HIV set of prevalence rate of 35.4 percent in the 15-49 age cohort with about 258,000 people infected out of a total population of 1.7 million, including babies of course.
This you will be surprised, in a way, marks a decline from the 38.5 percent in 2000 and 36.5 percent in 2001. One of the factors responsible for this seeming improvement is, of course, the death rate. As some people have died it would appear that therefore, statistically at least, there are fewer people living with HIV, relatively speaking.
HIV/AIDS is therefore undoubtedly the most serious development and health challenge that Botswana is facing. The impact of HIV/AIDS on socioeconomic development is already being felt. It is estimated that economic growth as measured by GDP growth could be slowed by up to 1.5 percentage points annually. Life expectancy has declined from 65 years to about 56 as shown by the 2001 national population census.
And several health and social indicators such as infant mortality, maternal mortality have suffered a reversal. As the pandemic affects mainly those in the most productive years, national productivity has declined. And the workforce in all sectors has been significantly affected.
In the early years of this pandemic its effects were not so clear to the ordinary person. But now its impact is clear for all to see. Our cemeteries are filled with the headstones of people in their 20s and 30s. Our health and social services are struggling to cope with the strain. Others in pediatric medical wards are frequently running above capacity.
HIV/AIDS-related illnesses account for about 60 percent of all acute medical beds. And our meager human resources in the health sector are severely stretched, in fact, to the limit.
Faced with an unprecedented challenge that threatens the very fabric of our society, we in Botswana have had to develop a comprehensive, multi-sectoral response to this pandemic. In the year 2000 I declared HIV/AIDS a national emergency and began to chair the National AIDS Council, the policy-making body on HIV/AIDS in the country. In the same year the National AIDS Coordinating Agency was established to lead the coordination of the multi-sectoral response.
To cope with a pandemic of so massive a scale requires resources well beyond the capability of a small economy such as ours. Therefore the people of Botswana and I are personally, are extremely grateful for the support that has been provided to us by, among others, the United States government. Our thanks also go to the private sector corporations such as the Bill and Melinda Gates Foundation, the Merck Company Foundation, Firelight Incorporated, Bristol-Myers Squibb and academic institutions such as the Harvard AIDS Institute, the Baylor College of Medicine in Texas and others.
We are also grateful to other development partners including the United Nations, of course, the United Nations Agencies for their committed support in our struggle. The UN system is particularly helpful in bringing to us best practices from other parts of the world in both management and coordination aspects of the pandemic.
While we greatly appreciate this support, we firmly recognize the importance of commitment of our own resources as a nation to the fight against HIV/AIDS. Our government has significantly increased funding for the national HIV/AIDS response and currently direct expenditure is estimated at about 70 million dollars annually by the government which is about 70 percent of total expenditure on AIDS.
From the outset we have recognized that with a generalized mature epidemic such as ours, any-long term control must forecast a strong, comprehensive and innovating preventive strategies; prevention of HIVs transmission therefore remains our most important priority and is a key aspect of the mobilization of our society.
In this regard, key interventions in the current national strategic framework for HIV/AIDS includes significantly increasing the number of people within the sexually active population, especially those in the 15-24 age cohort who are adopting key HIV prevention behaviors. It is also a stated aim to decrease HIV transmission from HIV positive mothers to their babies and adopt safe blood transfusion practices. Prevention is further predicated on promoting abstinence, faithfulness to partners as well as use of condoms. Capacity building of teachers in order for them to impart key prevention messages to the youth at an early age is also a key aspect of prevention.
Furthermore, specific population groups considered more vulnerable to HIV infection are having targeted programs. Condoms are freely available in all health facilities, workplaces and other places of convenience throughout the country.
We started providing free male condoms in government facilities [...] in order to increase options available to women in terms of protection against sexually transmitted infections including HIV/AIDS.
Consistent use of condoms during each sexual encounter still remains our greatest challenge in this area. It is our hope that with persistent information and education our people will use condoms more regularly as well as more effectively.
As a nation were cognizant of the fact that our future lies in protecting adolescents and youth from HIV/AIDS transmission. In fact our national mission 2016 has the ambitious goal of achieving an AIDS free generation by 2016. We have thus attached great importance to strengthening youth and adolescent sexual reproductive health programs. The Minister of Health in partnership with the African Youth Alliance funded by the Bill and Melinda Gates Foundation coordinates a project strengthening [...] responsibility for adolescent sexual and reproductive health in adopting sexually reproductive health programs to make them more accessible and effective to young people.
Botswana is one of the four countries benefiting under this program in Africa which has a budget of 7.9 million U.S. dollars over five years in Botswana. Implementing partners are, of course, the United Nations Fund for Population Activities, Program for Applied Technology and Health, PATH, and PATH International. This program is currently being implemented in ten out of 24 districts in the country and is in its third year of implementation.
The plan is to roll it out to the rest of the country as and when resources permit. Another intervention my government introduced was the prevention of mother to child transmission program in 1999. The program was slow to take off due to the problem of stigma to which the honorable Senators have just referred.
Many women were thus unwilling to test. Human resources have also been a major constraint of course. I am happy to inform you that introduction of lay counselors has helped in increasing the number of women counseled and tested. Currently more than 90 percent of women coming to natal care clinics are being pre-test counseled.
However we are still facing the challenge of increasing our testing figures above the current 60 percent and increasing the uptake to above 39 percent. To further minimize transmission of HIV in the community, treatment of sexually transmitted infections has been strengthened. As a result of this there has been, as Senator Feingold has mentioned, a downward trend in the prevalence of sexually transmitted diseases which is a side benefit.
Mr. Moderator, prevention of new infections alone is, of course, not sufficient. It is for this reason that 18 months ago my government with the support of ACHAP, a partnership between the Gates Foundation and Merck Company Foundation, introduced anti-retroviral therapy in our public health facilities at no cost to citizens. As a result of this partnership, 14 thousand people have been enrolled, of which, over nine thousand are receiving anti-retroviral drugs in government health facilities and a further five thousand eight hundred in private health facilities.
The 12 sites offering ARV therapy will be increased to 18 by the end of next year. This should extend coverage significantly. It is encouraging to know that as a result of intervention many people who were on their deathbed are back on their feet and are productively engaged and fending for themselves and their families. We are grateful to the Bristol-Myers Squibb through its Secure the Future program which has offered to assist us to introduce the anti-retroviral therapy in one of our rural areas. The major challenges in the introduction of ARV therapy have been human resource constraints, infrastructure, stigma, cost of drugs and reagents.
We are, of course, grateful for the price reduction in the cost of these life-saving drugs by the multinational pharmaceutical companies and hope to see further reductions, particularly in the area of reagents. Human resource constraints, especially pharmacists, doctors and health technicians, continue to be a challenge. We look to you our friends and well-wishers for supporting this area as well.
Mr. Moderator introduction of these interventions has made us realize that the entry point for all these programs is knowledge of ones HIV status. It is for this reason that in collaboration with the U.S. government we will introduce voluntary counseling and testing centers. A total of 16 of these centers are in operation. So far well over 65 thousand people have taken advantage of the services offered in these centers and have tested.
As we roll out all our programs to the rest of the country there is need for more of these centers. We hope it shall be possible to establish more of these centers all over the country under the auspices of President Bush Emergency Plan for AIDS Relief.
To further increase the number of those testing we have decided to introduce routine testing in our facilities starting early next year. It is our hope that placing HIV on the same level as other diseases in addition to increase public education will help reduce stigma.
Mr. Moderator in order for us to sustain the gains we have so far made it is critical for us to address the behavior of our people. We shall use every means possible to strengthen our social behavior change strategies. With assistance of our other collaborators such as the Baylor College of Medicine, the University of Pennsylvania, Harvard AIDS Institute, we are getting out a number of research projects, the outcome of which should be of interest and benefit to the rest of the world. This include, inter alia, development of resistance to ARV drugs, viral structure, the viral structure of our local strains, response to certain drug combinations in children, the use of anti-retrovirals in breastfeeding mothers and tuberculosis treatment.
In addition to these areas of research, these partners are also helping in the training of our healthcare providers in the areas of HIV/AIDS.
We have had successes and challenges in our anti-AIDS programs. The level of HIV/AIDS awareness and its socioeconomic implications in the public has risen considerably. There is more public discussion and openness than there was three years ago. All community leaders have become active proponents of our various programs. This is a system to break down barriers and promote common understanding and (unintelligible) by the general public.
This is a major success although we still have a long, long way to go especially in reducing stigma. We have initiated the prevention of mother to child transmission program, community home-based care of [unintelligible] and ARV programs. We train the recruited, skilled human resources. As many of you will bear me out we have established solid partnerships with international community, the private sector, NGOs, community-based organizations, faith-based organizations, the youth, womens groups, people living with HIV/AIDS as well as academic institutions. All of these people are represented at this meeting.
Our coordination mechanisms and the central and local government levels, the National AIDS Council and the district multi-sectoral AIDS committees among others are fairly well established and functioning quite well. But without [question] these have been tested by the scale of that epidemic and is [made] worse by the number of programs introduced. But equipment and retention of skilled human resources is problematic in the public sector and NGOs as well as community based organizations.
At the beginning of the program we lost our skilled health and other workers to the cooperating partners, including NGOs, all of whom pay better than the government. When our development partners require expertise they too recruit from government and other national institutions. This is cost-effective for them as locals cost substantially less than expatriates. This is a dilemma we face because when they do so they reduce our own ability to cooperate.
Well attempt to address this through more training of our own people, recruiting (unintelligible) qualified personnel from other African countries because those are the only ones we can afford to recruit and multi-scheme our available personnel. Well, I was saying recruiting from other African countries: of course when you do that you shall be, well, maybe its robbing Peter to pay Paul but anyway let us steal their people; we will, because we are more in trouble than they are.
Information technology capability will also be enhanced. Decision-making will be decentralized to the local authorities as and when appropriate and to other levels in line with our capacity to take on the roles delegated. We are constantly adopting our administrative procedures for procurement, staff recruitment, infrastructure development etc. to improve speed of delivery and effectiveness. And we remain open to considering whatever new initiatives that could further improve delivery.
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Ladies and gentlemen, the government of Botswana and other stakeholders will need the support of development partners to adequately staff, operate and manage our HIV/AIDS programs and to improve their efficiency. It should be borne in mind that one impact of the pandemic has been to reduce our (unintelligible) capacity to deal with it now that some of our own people have died. We have now recruited others. They have died.
And to the extent that we have suffered these losses, to that extent, our management capacity to deal with the problems has been diminished. And that is why some of the things we have done less quickly than we had intended or had hoped.
Our infrastructure development; we have not developed a number of facilities we had planned. Neither have we developed them at the pace we wanted to because of technical capacity constraints within our own construction industry. And our gain is partly a question of available skills. Government will continue to accord high priority to HIV/AIDS projects. But as it will appreciated, the development of other key infrastructures such as roads, power, water supplies etc. are also indirectly linked to the delivery of HIV/AIDS programs.
Mr. Moderator, distinguished guests, ladies and gentlemen; my government and I are determined to wage a decisive battle against HIV/AIDS. Every effort is being made to substantially increase involvement in the various HIV/AIDS programs. But the time, resource constraints, human material, financial and infrastructure frustrates our efforts. And on other occasions our own procedures have not been helpful to the speedy delivery of HIV/AIDS programs. The same applies to procedures, preferences and processes of partners sometimes; each of whom would like to be met individually as often as possible.
All these have contributed to the slow utilization of resources provided by partners and ourselves, the so-called absorptive capacity constraint. I am therefore confident that we can all work together and strengthen coordination mechanisms so that we can achieve the goals of our national strategic framework. It is critically important that for the various programs to be scaled up and new ones introduced the constraints I have referred to be fully addressed.
In conclusion, I should emphasize that mitigating the effects of HIV/AIDS on our population is also a major concern. People whose lives are prolonged must lead fully productive lives for as long as possible. They too must benefit from opportunities for employment, training and self actualization. In addition, they require care, support and most importantly our love and respect. Caring for orphans, of whom 42 thousand are presently registered, will be a particularly daunting but not insurmountable challenge. People living with HIV/AIDS and those affected are human beings no less deserving of human dignity.
Mr. Moderator, distinguished guests, ladies and gentlemen I am accompanied by the Honorable Minister, Assistant Minister of Local Government and various government officials and representatives of civil society organizations who shall later on speak to you on various topics of interest. We hope to continually engage with you in the implementation of our national strategic framework for HIV/AIDS. The national strategic framework outlines our major policy and program interventions. It is a document I commend to all our partners. I trust that you will stay the course with us and remain committed to more innovative and forward looking approaches to the fight against the HIV/AIDS pandemic. Together we shall overcome.
I thank you for your attention and thank you for your kindness in organizing this meetings.
[Transcript provided by the Kaiser Family Foundation at http://www.kaisernetwork.org/health_cast/hcast_index.cfm?display=detail&hc=1011]
