Chicago Tribune - March 6, 2005
Laurie Goering, Tribune foreign correspondent

A year later, most are nearly unrecognizable. One terribly wasted man, racked with tremors and forced to use a wheelchair, regained 12 pounds in his first two months on antiretroviral treatment and began walking again. A woman, brought in on a stretcher, now has a new job as a computer operator. Another rail-thin woman, hauled in by relatives from a distant village, is well enough to walk to the hospital from Mahalapye's community bus stop.

"Now, when she comes in, she says, 'Look at me! I'm pretty!'" said Gaelebale Raphorok, a hospital nurse. With treatment, "these people feel they get their life back."

Since 2002, when Botswana became the first African country to offer free antiretroviral drugs to everyone in need of therapy, the nation has become the continent's model for treatment. The rural, thinly populated country of 1.7 million has one of the world's worst HIV epidemics with nearly 40 percent of adults infected, and life expectancy has fallen to just 39 years, down from a pre-epidemic expectation of 72 years.

In December the government and its partner organizations finished opening 31 treatment centers across the country, many in rural outposts such as Mahalapye. That has allowed 38,000 Batswana, as people here are known, to enter treatment--nearly 40 percent of population in need of drug therapy for HIV or AIDS.

The treatment rate is by far the highest in Africa, a continent where most countries struggle to treat a fraction of 1 percent of those who need care.

'HIV not a death sentence'

In Botswana, "the reality now is that HIV is not a death sentence," said Dr. Ernest Darkoh, who oversaw the planning and management of the country's antiretroviral drug rollout. Instead, he said, the program is gradually turning HIV infection into yet another treatable chronic disease.

But Africa's first effort at widespread treatment also is raising concerns and questions that may reverberate across the continent as therapy programs spread. In some cases, doctors in Botswana fear the new availability of life-extending drugs may be reducing fears of catching the virus, which could increase the country's already high infection rate.

Though patients so far have shown excellent commitment to sticking with their drug regimes--officials say adherence is better than 85 percent--doctors fear that tally could fade over time as the sick recover and symptoms fade. Others worry that international donors who have picked up about 40 percent of the cost of Botswana's treatment program eventually could lose interest in paying for lifelong treatment for tens of thousands of people.

Then there are the social concerns, from sick workers recovering and turning back up at their jobs only to find they have been replaced, to the poorest of the HIV-positive trying to make themselves sicker to become eligible for drugs and assistance food baskets, doctors say.

If Botswana fails to slow new infections or keep people on their drug regimes, "we will have a second wave of an epidemic that will be even more difficult and expensive to handle," warned Dr. Patson Mazonde, Botswana's director of health services.

Botswana's successes or failures also may determine whether millions of other Africans in need of the drugs get them, and even whether the continent succeeds in defeating an epidemic that killed more than 2 million Africans last year.

"If [treatment] is not going to work in Botswana, how can it work elsewhere?" said Brad Ryder, a spokesman for the African Comprehensive HIV/AIDS Partnerships, or ACHAP, an organization backed by drugmaker Merck and the Bill and Melinda Gates Foundation. So far it has provided $18 million, plus donated Merck drugs, toward Botswana's treatment effort.

Mahalapye's antiretroviral treatment program, which began a year and a half ago, may well indicate how the country's treatment battle will go.

Each day about 40 patients on HIV drugs gather beneath a plastic sun canopy at the hospital, awaiting their chance to see one of two doctors on duty. Antiretroviral patients make up 20 percent of the hospital's caseload, said Dr. Kunal Bose, the chief medical officer.

Doctors, initially overwhelmed by a rush of patients and by their own unfamiliarity with the drugs, have slowly gotten more efficient. But tracking the hospital's growing caseload--1,285 people on treatment, 3,000 getting regular immune system tests--is taxing, despite new computers provided by ACHAP.

Most doctors in Botswana believe tracking and managing the huge treatment program is one of the biggest challenges facing Botswana's campaign, and those getting started elsewhere in Africa. Just last month, neighboring South Africa's health minister acknowledged she had no idea how many people were taking government-provided drugs or sticking to the fledgling treatment plan there.

"As a whole, Africa suffers from very weak systems. You can't distribute aspirin well, much less ARVs," Darkoh said. With antiretroviral drugs, "follow-up is still the real work, making sure pill No. 1,000 is taken, as well as pill No. 1," he said.

Attitudes about sex at issue

Changing sexual behavior to prevent new infections also is tricky. Mazonde said the incidence of sexually transmitted diseases seems to be on the decline in Botswana and that condom use is rising dramatically, if only judging by the number of used condoms tossed on the roadside. That may mean the HIV infection rate is dropping.

But at Mahalapye, "we just don't know yet," Bose said. "It's a hard thing to say."

Men continue to resist going for testing--now done on all patients who visit hospitals with possible AIDS symptoms--and many have partners outside marriage or resist condom use. That may mean the infection still is spreading widely, he said.

Bose also believes fears of catching HIV may be easing somewhat now that the disease is treatable and communities see the very ill recovering.

"It's a worry," he said. But the widespread recoveries also mean "lots of people are now coming forward [for testing] now that they know there's something for them."

About 30 percent of Batswana now know their HIV status, compared with about 1 percent in most African countries, Darkoh said.

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