Unsustainable ARVs 'jails the HIV-positive'

| Friday January 21, 2011 00:00

In the findings of Kitso Aids Training Programme made public in 2008, as of January 2007, for instance, there were 60,000 cumulative HIV/AIDS-related deaths. Kitso Aids Training Programme is an NGO working with HIV/AIDS specialists in combating the dreaded disease in Botswana.

This shows an increase in HIV/AIDS-related deaths when the 2003 estimates of 33,000 are considered. In 2003, 350,000 persons were estimated to be living with HIV/AIDS, which resulted into 33,000 deaths within the same year.  But the government of Botswana, in conjunction with NGOs, is determined to strangle the devastation that the scourge is visiting upon its citizens.

In February 2007, the Ministry of Health convened the Committee for the Clinical Care of HIV/AIDS in Botswana, with instructions to review and, as necessary, revise the country's 2005 National ARV Guidelines. A further charge to the committee was to integrate into the guidelines any indicated recommendations concerning HIV testing, prevention, HIV/TB co-infection, Prevention of Mother-To-Child Transmission, and opportunistic infections.

By January 2007, the total number of persons on HAART or Highly Active Antiretroviral Therapy in Botswana was standing at 81,437. The breakdown on HAART by 2009 in the Public Sector alone was 67,879 as the Private Sector takes an approximate 8,500 persons on the HAART pie. HAART enrolment target for 2009/2010 was 125,000 persons but the actual target wanted 140,000 persons during that period.

Separately but closely-knitted, out of an estimated population of 1.8 million persons, according to Dr Frank Apondi, an HIV/AIDS specialist in private practice, about 300,000 persons in the urban areas are on ARVs while another approximate 400,000 living in rural areas are accessing the life-extending drug especially through NGOs in partnership with the government of Botswana. 'The ARV programme is well-funded by government and NGOs,' says the specialist. 'But cultural barriers like multiple partnerships and traditional medicine impede the success of the ARV programme in Botswana,' he laments.

Traditional medicine, explains Dr Apondi, when criss-crossed with ARVs, is better known in clinical terminology, as 'drug interaction' which disables the effectiveness of ARVs and this, he points out, is the biggest challenge that the life-prolonging drug is facing in Botswana. Such are also impediments that he blames for the estimated 5 percent yearly rate of infection; alongside the mobility of the general populance that makes it difficult for clinicians and health workers to maintain a register for HIV/AIDS patients on ARVs. On why the number of people on ARVs is surging, Dr Apondi says given the high prevalence rate, people are going for voluntary counselling and testing but regrets that some people have not yet been reached with the anti-HIV/AIDS messages. Perhaps this explains the high prevalence especially among the unmarried couples at the active age of 15-40 years, who, he says, 'are mostly affected'. '[For example] college students--- aged between 15-29 years - sponsored by government are always jumping up and down. And then the 30 to 40-year employed age bracket who have money [to spend] get excited and forget about preventing HIV/AIDS,' he says. The Botswana government-sponsored students enjoy allowances, which, instead, some students spend indulging in alcohol and all the other pleasures that come with the world of entertainment.

The government has, for a long time, cited alcohol indulgence as an obstacle to the war against HIV/AIDS in Botswana. To prune this obstacle, among other reasons, the government, on November 1, 2008, slapped a 30 per cent additional levy on alcoholic beverages.  'Researchers have... found that heavy [alcohol] drinkers are much more likely to be non-adherent to ARVs, than those who do not drink. This is a very serious finding which could have devastating effects in a country where most of the population is on ARV medication,' Vice President Mompati Merafhe, in defending the government's then expected 30 per cent levy on alcohol, told an All Churches rally against HIV transmission, September 16, 2008. Another 9.87 per cent price increment on alcohol was implemented on January 12, 2009. Additional 10 per cent levy followed on December 1, 2010; further stemming and taming non-toteetallers' voracious guzzling habits.

But Dr Apondi's worry is that although people are trying to prevent and reduce infection rate of HIV/AIDS, the prevention method is stagnant because of the same approach of the 1980s - Abstain, Be Faithful, and Condomise, or ABC. 'Government and NGOs are only modernising information but the techniques remain the same. And some NGOs [could be] out to make money,' Dr Apondi explains.

 On the possibility that the ARV Programme may become unsustainable, he says that some people are on ARVs yet they maybe HIV-negative. This, he regrets, is caused by the shortage of competent personnel to manage HIV testing.  Asked about how she feels being HIV-positive, 29-year-old Pinki, (not her real name) is fully counselled and ready for life like any other HIV-negative person. 'I am okay now; there is no difference [with an HIV-negative person].  If I woke up and found an inscription on my body 'HIV-positive' [she smiles touching her arm], I would have felt like dying [implying the importance of knowing one's HIV status] - by committing suicide - before anyone sees such inscription,' she laughs.

She says she discovered her status through voluntary testing and counselling in February 2008. Aware that HIV/AIDS does not kill but opportunistic infections do, Pinki is not jelly-hearted: 'All I have to do now is to take care of myself, [go for] continuous counselling and condomise.'  With a CD4 count of 810, Pinki is confident that she is still strong as her doctor told her that a person can enrol for ARVs once the CD4 count lowers to 200 or less; although the World Health Organisation recommends the CD4 count of 350 or less following which one must enrol for the virus-suppressing pills. CD4 count immune cells fight infections in the human body. An HIV-negative healthy person's CD4 count is over 410. 

Reminded that on World AIDS Day, December 1, 2008, in Selebi-Phikwe, President Ian Khama said the ARV programme may become unsustainable, Pinki is distressed: '...that will be jail for us [HIV-positive people who will need ARVs]. Don't show me that article; I will get sick now...I cannot manage to afford ARVs.' In a related development, and in concurrence with Pinki that unsustainability of ARVs will be jail for the HIV-infected citizens, a 34-year-old man says, 'then they [government] will be killing people'. The civil servant, speaking on confidential grounds for fear of possible retribution, continues: 'It will be a death sentence; but jailed at home.'

He says that if government stops or fails to provide ARVs for its citizens, then it will imply government will be reducing the population. 'Nobody will be able to afford ARVs because even those who are working have not had salary increments yet there is inflation,' he says. A monthly dose of ARVs is said to be as costly as P500.

The Zion Christian Church believer says he roots for government levy on alcohol not because he is such a Christian but because when it comes to ARVs, 'those [HIV-positive] people [on ARVs] are not only cheating government but themselves, too'. 'There is already an intoxicant in ARVs and drinking alcohol while on ARVs makes them more drunk and weakens the drug,' adds the committee secretary, HIV/AIDS Committee, at his workplace. 'Just imagine someone who is on ARVs being picked by a friend [from Gaborone] to go and drink, say, in Mogodishane, which means he will get drunk and forget the medication because he will have left them at home!'

Pinki's partner, on the other hand, does not know his status. Told that he could be discordant - when one sexual partner is HIV-positive and the other negative - but only and only verifiable through routine counselling and testing, he curtly retorts: '...as long as our government [of Botswana] is there, we shall be getting ARVs. AIDS is a 'normal disease'.'

Currently, Botswana citizens access ARVs free of charge.  The government was also applauded by NGOs - in January 2009 - for passing the Public Service Act of 2008 which stipulates that no employee shall be treated unfavourably or prejudiced for their HIV-positive status. Botswana was the first sub-Saharan African country to introduce routine HIV testing (RHT) with the objective to report programme data for the first two and half years of RHT. Introduced in 2004, rapid HIV tests were introduced later the same year and are widely available. The main criteria for RHT are symptoms of HIV/AIDS, pregnancy, sexually transmitted infection, and attendance for medical examination but testing may also be self-initiated.

And findings on RHT in Botswana by Journal of Acquired Immune Deficiency Syndromes, April 1, 2007, indicates a rapid scale-up of RHT.  A total of 60,846 persons were tested through RHT in 2004 versus 157,894 in 2005 and 88, 218 in the first half of 2006. The proportion of men who were tested HIV-positive was 34 per cent versus 30 per cent for women. 'RHT has been widely accepted by the population, and no adverse effects or instances have been reported,' says the findings. 'It [RHT] has provided increased access to preventive services and earlier assessment for antiretroviral treatment,' it concludes.