Botswana: An African success story in the fight against AIDS

Former President of Botswana Festus Mogae

The southern African nation of Botswana has one of the world’s highest rates of HIV infection and yet is also widely considered one of the big success stories in the fight against AIDS.

On Tuesday, at a Seattle event sponsored by the World Affairs Council, former Botswanan President Festus Gontebanye Mogae spoke and took questions from an audience of several hundred people at the Bell Harbor International Conference Center.

Former President of Botswana Festus Mogae
Tom Paulson

Mogae began his remarks by recalling when AIDS was first recognized in some central African countries and was largely ignored as another one of those “mysterious diseases” that afflict or kill a few people, attract some scientists and media attention and then just as mysteriously ebb away.

Not this time.

Botswana would soon have (and still does have) one of the highest rates of HIV infection in the world. At the peak of the pandemic, nearly 40 percent of Botswana’a adult population was infected. That’s come down some, but today still one of every four Botswanans between the ages of 15-49 is estimated to carry HIV.

“We didn’t know what hit us,” Mogae said. “We were faced with the possibility of extinction.”

It’s important to recognize that prior to AIDS, Botswana had been one of Africa’s brightest hopes. Its economy had been been improving, stable and responsible governance was the norm and life expectancy for for men and women had been about 65 years old. With AIDS, average life expectancy fell to about 40 years old.

The same thing was happening in neighboring South Africa, which as a larger nation had a lower overall percentage of its population infected but a much greater total number of people with HIV and AIDS. South African President Thabo Mbeki wasn’t helping matters by questioning whether or not HIV was the cause of AIDS.

Mogae became President of Botswana in 1998, after new anti-retroviral (ARV) drugs had been discovered that could prevent AIDS in HIV-infected people. But the drugs were considered too expensive and complicated to manage for poor parts of Africa.

“I remember people saying you can’t treat Africans (with the drugs) because they don’t have watches,” said Rep. Jim McDermott, D-Wash, who moderated Mogae’s Q7A last night at Bell Harbor.

“Many said it was irresponsible to even talk about treatment for Africa,” said Mogae. The thinking, he said, was that even considering it raised unreasonable expectations that would only inflame this massive tragedy.

But Mogae, whom McDermott and many others have praised as one of Africa’s most progressive political leaders, was not willing to simply accept that Africans had to die. He began talking with pharmaceutical companies and asking them to consider discounting the drugs for Botswana.

“We told the pharmaceutical companies we could afford about 5 percent of their price,” Mogae said. Some firms dismissed the idea as absurd, he said, but one did not. Merck.

There was also this relatively new philanthropy out of Seattle run by this software guy who seemed interested in global health projects.

The Bill & Melinda Gates Foundation was, at the time, still forming its strategy for global health but one thing Bill Gates had been pretty clear about from the start of his foray into matters of disease in the developing world is that they would emphasize disease prevention, not treatment.

Even the world’s biggest philanthropy could not expect to pay for AIDS treatment. It was a “black hole,” Bill Gates reportedly said at one point, that would overwhelm his new philanthropy’s chance of making a difference.

Well, somebody appears to have changed Gates’ mind. Maybe it was Mogae who somehow convinced the Gates Foundation to take a big risk. Maybe it was Merck. I’m still not sure how Gates was convinced to break so dramatically from his emphasis on prevention and away from treatment, but he did.

In 2000, the Seattle philanthropy and Merck stunned many by announcing the launch of a $100 million program aimed at getting ARV drugs to anyone who needs them. One of the requirements was that the program also launch aggressive prevention efforts and evaluate their effectiveness.

“We are pleased to support such a comprehensive HIV/AIDS intervention program,” said Dr. Gordon Perkin, the first head of global health for the Gates Foundation. “We look forward to working with Merck, our other partners, and the people of Botswana. This well-conceived plan brings together the best of the public and private sectors to demonstrate a sustainable, comprehensive HIV/AIDS prevention and care program.”

As a result, Botswana became the first African nation to guarantee treatment for everyone infected with HIV. ‘

It was viewed skeptically at the time by many, and by many others as a critical turning point in Africa’s battle against AIDS. As The Guardian reported in 2002, if the program fails to show progress it would damage plans to expand treatment throughout the rest of Africa.

Mogae was instrumental in making the program a success. He was publicly tested for HIV to encourage others to seek testing and counseling. He pressed for new laws protecting gays and others from discrimination because he recognized the critical need for such protections as a public health measure.

Mogae also noted that Gates and Merck were willing to fund the Botswana treatment-prevention project because the country already had an established, functioning health system.

“They were willing to help us because our primary care system was one of the best in the developing world,” Mogae said.

There were many factors, and players, who helped turn around the terrible death toll and potential unraveling of Botswana. The former president thanked a lot of people and organizations last night at Bell Harbor, at one point even characterizing President George W. Bush and liberal Congressman McDermott as belonging to the same category of pro-African humanitarians.

“Today, this virus is no longer a death sentence,” Mogae said. “People are no longer getting rich as undertakers and the coffin factory has closed.”

Botswana and Mogae proved the skeptics wrong, that it is both possible and beneficial to make sure everyone with HIV in Africa has access to treatment.

Still, millions with HIV in Africa have no access to these drugs, and there are signs of a dilution of the past decade’s efforts to get everyone infected on treatment. New studies have shown ARVs reduce viral load to near zero, effectively making manifest the old activists’ chant that “treatment is prevention.”

But so far, funding has not kept pace with the need for AIDS treatment. The Global Fund to Fight AIDS, TB and Malaria failed to obtain even the minimum amount requested.

Mogae said he believes everyone infected with HIV has a right to these life-saving drugs, to treatment.

“But whether or not you have that right does not mean you will get them,” he said.

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Tom Paulson

Tom Paulson is founder and lead journalist at Humanosphere. Prior to operating this online news site, he reported on science,  medicine, health policy, aid and development for the Seattle Post-Intelligencer. Contact him at tom[at]humanosphere.org or follow him on Twitter @tompaulson.