Race against time

The wealthy African nation of Botswana is at the forefront in the aggressive war against AIDS. With an infection rate of 37.4 percent, the fight for treatment and cures is critical, but hardly progressing.

	[Times photo: John Pendygraft]
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GABORONE, Botswana - To much of the world, this is the face of AIDS in Africa: A skeletal figure, legs mottled with sores, lies on a mattress on a hospital floor. There are so many patients with AIDS the hospital doesn't have beds for them all.

But this too is the face of AIDS: A round-cheeked young woman breaks into a smile as she strokes the silky fabric on her lap. A few months ago she was considered terminally ill; now she has a small business making shawls.

"I thank God every morning that I have seen the moon and the sun," says Gofaone Letlhaselwa. "In my mind, I feel I'm going to live longer."

Twice a day, this mother of four takes AIDS-fighting drugs that she gets free of charge through a government program. At least once a month, she sees a doctor, again at no cost. Samples of her blood are tested in Africa's most modern laboratory, in the same building where promising research is under way to develop an AIDS vaccine.

And almost everywhere she goes she sees signs and billboards:

You can get AIDS from sharing blades

Condomise and stay alive

Too much alcohol can lead to unprotected sex

Few places have been more ravaged by AIDS than Botswana, a nation of 1.8-million where almost four of every 10 people are infected with the AIDS-causing HIV virus. Life expectancy has plunged to 37 - lower than Haiti's - while the HIV rate until recently was the highest in the world.

Yet few countries have been more aggressive in fighting a scourge that still inspires so much dread, fear and denial. While other African leaders reacted slowly to the continent's AIDS epidemic, President Festus Mogae warned in 2000 that AIDS could literally drive his country to extinction.

Since then, Botswana's war against AIDS has drawn international support, including a huge donation from Microsoft founder Bill Gates. Doctors and researchers from Harvard, Florida International and other American universities are at work in the country.

But almost three years after Botswana rolled out Africa's most ambitious program, the HIV infection rate stands at 37.4 percent, second only to that in Swaziland.

"Our worry is 2010, when at the current rate of attrition the government will cease to function," says Tim Jones, manager of Princess Marina Hospital in Gaborone. The hospital has space for 507 patients, but on a recent day it overflowed with 658 - most of them infected with HIV.

"We won't have enough people to keep the lights on, to pay the bills - that's how scary it is," Jones says. "It attacks people who are the most productive in society. It's an enormous race against time to find treatment, cures, a vaccine."

In Botswana, AIDS has taken aim at what may be Africa's most remarkable success story.

A vast, arid land the size of Texas, Botswana seemed so lacking in natural resources that no European country wanted to colonize it. Britain made it a protectorate only after local farmers pleaded for help when hostilities broke out with white settlers from what is now South Africa.

At independence in 1966, Botswana ranked as the world's sixth poorest nation. But diamonds were discovered just a year later, and by the early 1980s, Botswana had become the world's largest producer of gem diamonds.

That natural wealth, coupled with a stable, democratic government, led to other superlatives. World's fastest growing economy. Africa's least corrupt nation. The highest credit rating of any African country.

Today Botswana, with a per capita income of $3,000, enjoys a higher standard of living than residents of Turkey, Brazil and South Africa. The capital, Gaborone, boasts shopping malls that rival those in any American city. There are Jaguar, Lexus and Mercedes dealerships.

Botswana "has managed its wealth well," Jones says. "It created a society that mirrors the West - high, middle and low classes. That produces stability because people see they can go from nothing to being president.

"But what's so tragic is that all the good work is being undone. Life expectancy went from 42 at independence to 70, and then this bloody AIDS came along and now it's 37. And that's the biggest hurt of all."

One reason for the AIDS crisis is that Botswana, like many African nations, is a male-dominant society in which men like to brag about the number of women they've had.

"Men, they want free sex here," says Florence Modukanele, director of a hospice that helps AIDS patients. "They don't want to wear condoms - that's the real issue."

Botswana's relative affluence was also a factor, enabling more people to afford cars and enjoy a newfound mobility that hastened the virus' spread among heterosexuals.

By the mid '90s, the country was deeply in the throes of AIDS. But in a culture where the sick traditionally have been hidden away, AIDS was a taboo subject.

"One thing that really surprised me was how little HIV/AIDS was really talked about," says Dr. William Wester, a research associate in the Botswana-Harvard AIDS partnership. "One-third of pregnant women were infected, but there was still a high stigma with an AIDS diagnosis. It seemed to be everybody else's problem."

In 2001, Harvard started a small clinic at Princess Marina Hospital, initially serving just 308 patients. Efforts to help more people got a huge boost when the Bill & Melinda Gates Foundation and the Merck pharmaceutical company pledged a total of $100-million over five years.

In early 2002, Botswana rolled out its national Masa program - the native word for "New Dawn." It offers antiretroviral therapy to any citizen with an AIDS-related illness, including certain cancers, or those whose immune systems are seriously weakened.

Today, 17 treatment centers are spread throughout the country, with 15 more planned. The original Harvard clinic now has 10,000 patients and is thought to be the largest AIDS clinic in the world.

"On a good day each doctor sees 25 to 30 patients," says Dr. Tendani Gaolathe, the co-director. "On a bad day we see 60 to 70 - it's that busy. The hardest part of the job is dealing with the sickest, but it's a reward three months later to see them much better."

Among those "living positively with AIDS" - as one inspirational slogan puts it - is 32-year-old Kgalaleo Ntsepe.

Although she felt ill for for years, Ntsepe couldn't bring herself to be tested for HIV until July 3, 2001 - "a day I'll never forget." By then she had night sweats and could barely walk because her legs were so swollen.

Ntsepe thinks she contracted HIV from a now-dead boyfriend, but admits, "I was having many affairs. I didn't worry at the time, I was just a person who was ignorant about HIV. I was drinking - drinking is the most dangerous thing. I remember one day waking up with somebody I didn't even know because I had been drinking so much."

After she started what will be a lifelong regimen of medication, Ntsepe's health improved. Last year, the statuesque youth counselor won a beauty pageant - Miss HIV Stigma Free Botswana - and now tours the country giving speeches on the importance of testing and treatment. She hopes to marry but wants to adopt - at least 67,000 children are "AIDS orphans" who have lost both parents.

Botswanan law bars discrimination against those with HIV, and businesses are encouraged to offer AIDS awareness programs and even provide condoms for employees. But only a few people have followed Ntsepe's lead and "come out" - publicly acknowledging they are HIV-positive.

"You hear (rumors) about rich or famous people going to America for treatment because they don't want their status known," she says. "But I think the truth sets you free. If many people can talk about it, the stigma will be low."

That stigma, along with a fear of discovering they have an incurable disease, has kept many from even being tested for HIV. Concerned that thousands of people still don't know their status, President Mogae earlier this year ordered that a free HIV test be offered to anyone seen in the public health care system.

(Mogae publicly revealed his own results - negative.)

Most of those offered the test have taken it, authorities say. But women still make up more than 60 percent of those tested and treated.

"Because of pregnancy a lot of women have the test," says Gaolathe, the clinic co-director. "Most will say, "I want to see my child grow up.'

"Men are much more resistant than women. Men in general never seek health care until very late, and they're socially irresponsible for a number of reasons."

Tsholofelo Ranko, 24, is certain she was infected by her boyfriend, the only man she ever slept with, she says. He ran away in 2002 when she told him she was expecting.

Under a national mother-and-child program, Ranko took medication eight months into her pregnancy to prevent transmission of HIV to the fetus. Now 2, her son is virus-free, and Ranko herself is still healthy enough that she does not yet need additional treatment.

As for the ex-boyfriend, "He has a new girl, but I don't think she knows he has HIV because he refused to go for a test."

Botswana's battle against AIDS has important ramifications for other hard-hit countries. Botswanan researchers are working on a vaccine for Subtype C, the cause of the AIDS epidemic in Africa and, increasingly, in Asia.

Other research is under way to determine when to start treatment - a big consideration for countries that may not be able to afford expensive drugs.

Of particular concern is the spread of AIDS in neighboring South Africa, where President Thabo Mbeki has been sharply criticized for downplaying the crisis. (He has denied that HIV causes AIDS and recently said he didn't know anyone who had died of AIDS.)

"South Africa's epidemic is so much bigger," says Wester of the Botswana-Harvard program. "Here about 80,000 people need treatment - in South Africa it's 5-million to 6-million. The magnitude is overwhelming."

With staff a major cost in any AIDS program, South Africa and other countries would be smart to hire more nurses, Wester says. Most patients on treatment are relatively stable and don't need as much attention from doctors, whose salaries are much higher.

In Botswana, thousands of people with HIV have returned to work or school and can expect a nearly normal life span, based on the experience of Western countries where antiretroviral therapy has been used for years. Almost 20 percent of the 6,500 employees of Debswana, Botswana's big diamond-mining company, are HIV-positive, yet only a few died last year.

But despite Botswana's many advantages and resources, HIV remains a tenacious foe.

"Botswana has a big problem but not big numbers," Wester says. "If Botswana can't do it well and successfully, it doesn't offer much to neighboring countries not blessed with political stability and all the other factors."

Susan Taylor Martin can be contacted at susan@sptimes.com

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