Recently in HIV in Botswana Category

I recently presented an abstract, Kicking up Male Interest in VCT via Community-led HIV/AIDS Activities in Rural Botswana, at the HIV Implementers Meeting in Kampala, Uganda. The purpose of the conference was to exchange best practices and research from PEPFAR-supported countries in Africa and other heavily impacted regions. I attended last year’s conference in Kigali, Rwanda, but this was my first opportunity to present at such a forum.

Although the theme of the conference was Scaling-Up Through Partnerships, the main message might as well been “nothing is working in the area of HIV prevention.” Many commentators and researchers noted that HIV testing and abstinence campaigns have not yielded a decrease in HIV incidence in Africa. While these approaches are important and needed in certain respects, however, there is consensus that much more resources and attention needs to be focused on adult male circumcision, breaking up concurrent sexual relationships (e.g., “secret lovers” or “small houses), and to a lesser extent, supporting consistent condom use.

Though I don’t close my service until the end of June, presenting on Zebras4Life—Test4Life was a great way to conclude my unique, non-traditional work as a Peace Corps volunteer in Botswana. While my presentation was well received, there were some expected points of contention, mostly with the need to promote voluntary counseling and testing at all.

I still believe that VCT is important and that our approach helping. For starters, men in Botswana have a higher incidence of TB, commonly an HIV co-infection. Fewer men, proportionally to those infected, are not on treatment. Not to mention that having men test for HIV on their own terms has implications for reducing gender-based violence. Moreover, I think that having on-going, supportive counseling by trained counselors and trained peers, the future the Zebras project, can effectively support behavior change. Perhaps most significantly, however, VCT may become a gateway to male circumcision services. So it’s important for VCT to be male-friendly, which is the purpose of Zebras4Life—Test4Life.

Pic: Me presenting at the conference. I just had to wear the national team colors.

The most recent report to Congress from the President's Emergency Plan for AIDS Relief noted the success of Zebras4Life at linking men to HIV testing. The photo of Zebras defender Khumo "Shoes" Motlhabane, catured at an event in Pandamatanga, along with with caption at left appeared in the Care section of the full report. The numbers, however, are out of date and have been vastly exceeded in the past few months. But hey, it's pretty cool to get mentioned as success story in the global effort against HIV/AIDS. The commitment from Tebelopele staff and counsellors, the American Embassy and CDC in Botswana, the Zebras/BFA, and the Botswana government cannot be understated.
In my personal opinion, the Bush administration deserves a lot of credit for committing $15 billion over five years for global efforts to address HIV/AIDS. Some of the early controversies have been blown way out of proportion by pundits and special interest groups, such as the 'A' provision and "underfunding" during the first few years. That being said, I hope in the near future that PEPFAR places more emphasis on deploying skilled personal to help build capacity, increases its commitment to prevention programming, funds the whole package of family planning when culturally appropriate, and improves the quality and effectiveness of interventions.

Links: Fourth Annual PEPFAR Report | About PEPFAR | The Zebras & BFA

Mascom Premier League leading scorer and national soccer team star Pontsho Moloi spoke about the Zebras' HIV testing campaign in an interview with The Voice on Friday. The article is titled, Captaining the Chiefs.

The best part about the article is that Pontsho was speaking from his own experience and beliefs that relate HIV testing to family planning. In Botswana, many men have the habit of testing through their partners (i.e., assuming their HIV status is the same as their partners). They will wait until after their wife or girlfriend falls pregnant and receives antenatal care, where HIV testing uptake is over 80 percent, to assume their HIV status. This is problematic for a number of a number of reasons (e.g., implications for parinatal transmission as PMTCT is not 100 percent full proof, possibility of discordancy within the couple, potential for gender-based violence, etc.). That is why it is important for men to know their status conclusively and on their own merits.

An excerpt from Pontsho's interview:

THE VOICE: You are also an ambassador in the ‘Zebras4life test4life’ initiative. Can you shed more light on it?

PONTSHO: That is an initiative for every Motswana male; every male supporter of the Zebras is encouraged through this programme to test and know their HIV status. Those who test with Tebelopele, are given a blue wristband, like the one I am wearing (shows off his two blue wrist bands). We were targeted to spearhead the campaign because statistics showed that most men were not coming forward to test for HIV and therefore did not know their status. So we are tasked with going around the country, addressing public gatherings and encouraging men to test.

THE VOICE: How has the reaction been so far?

PONTSHO: I have been to Maun with Tshepho ‘Talk Talk’ Motlhabankwe. I am told the number of men who tested was quite amazing after we addressed them. It is a face to face scenario with us and the fans ask any type of questions. Some take advice and test and of course some only want to know about the Zebras.

THE VOICE: Have you been tested and have you spoken to your younger brother Dirang about it?

PONTSHO: You can’t ask me if I have been tested. How would I have the blue wristband if I had not? I have, of course, talked to Dirang about testing even though he doesn’t take me seriously.

THE VOICE: I'm told you have a baby. Did you test after making her or before?

PONTSHO: I went for HIV tests with my girlfriend and we decided to make a baby knowing our status. It is not a good idea to make indirect tests by impregnating somebody. You can never know unless you test the right way.

If only there were more athletes like Pontsho...

Image: Pontsho Moloi trading card.

Botswana is often seen as a success story in the effort against HIV/AIDS. It was the first African country to provide eligible citizens with life-saving antiretroviral treatments. Furthermore, its PMTCT program has reduced perinatal HIV infections from approximately one-third of infants born to HIV+ mothers to less than 5 percent, a rate comparable to the developing world. Voluntary counseling and testing services, male and female condoms, contraceptives, TB treatment, TB preventative therapy, and other supportive services are available at no cost to citizens. Unfortunately, the adult HIV prevalence stands at 25 percent and a lot of factors are pointing to a sustained incidence of HIV infection.

Fully addressing Botswana’s HIV/AIDS problem is multifaceted and resource dependant, but a lot of it comes down to knowledge and behavior. More especially, “building a bridge” between knowledge of HIV/AIDS and one’s sexual behavior behavior. Heather and I have found that tackling this issue in Botswana is tricky. For starters, even in Botswana knowledge of HIV is still something to be desired. According to a major Botswana government study in 2004, one-third of people believe HIV can be transmitted by witchcraft, one-half believe it can be transmitted by mosquito, and nearly one-quarter believe that a healthy-looking person can’t have AIDS. This has serious ramifications for linking HIV knowledge to behaviors. I believe that it’s important for everyone to understand that you get HIV from having unprotected sex (yes, there are other ways, but over 90 percent of infections are through heterosexual sexual intercourse). I don’t like giving people an out (e.g., “I once cared for my uncle who has AIDS and he may have bleed on me.”) because that allows people to evade responsibility for their actions.

In Molepolole, Heather and I sought out any opportunity to educate, and train other to educate, on HIV, AIDS and STIs. We wanted to help people understand that their actions have consequences and that there are strategies to reduce or eliminate your risk of HIV exposure. Our first challenge in leading sessions and training others was the lack of quality HIV/AIDS educational manuals available locally—unnerving considering Botswana’s HIV/AIDS situation. Also, the plethora of government services resulted in many HIV education outlines being nothing more than definitions of acronyms (e.g., IPT, HAART, PMTCT, etc.) and stating the objectives of national programmes. While somewhat important, that’s unlikely to lead to behavior change. The other problem we encountered was that the HIV training manuals produced by Peace Corps were either too vague or not conceptualized for situation in Botswana.

So we set out to write/compile an HIV/AIDS lesson book of own following behavior change theory and the advice of philosopher John Dewey:

The guidebook now in use helps engage participants in discussions and activities that apply knowledge and relate it to behavioral strategies. Anne from Bots2 provided some original artwork and updated/revised a few illustrations. Take a look at the guidebook. Let us know what you think.

Peer_Education_for_Behavior_Change.pdf

Headquarters in Washington, D.C. sent out a press release in advance of December 1st titled, Peace Corps Turns Hope Into Action On World AIDS Day. The Zebras project was highlighted as key volunteer-led intervention:

In Botswana, Volunteers are working with voluntary testing and counseling centers to help implement the Zebras for Life--Test for Life campaign, which promotes behavior change among football fans, and encourages young people to get tested. Those who complete the full counseling and testing process receive a [blue] bracelet with the campaign's message inscribed. Several players from the Zebra national football team serve as role models and spokespeople for the campaign.

The campaign was also recently praised by local leaders in the Kgalagadi District in a Botswana Daily News article on November 27th titled, Dikereke le borre, matshego a tsholofelo (the article is in Setswana).

This kind of recognition motivates me to keep pushing myself and the campaign, especially considering all of the logistical problems we've suffered through lately. We hoped to end the year with several strong events, but things kind of fizzled out and we had to pull back and regroup for next year. On a more positive note, the data that is coming in shows that the campaign is working: Men are testing in higher numbers, Tebelopele's ration of male-to-female clients is nearly even, and testing centres are posting all time highs in client loads. Scott, Hannah, and all Peace Corps volunteers in Botswana past and present should be proud of their efforts.

Photo: Brian and Libby pose with Botswana national team players and HIV testing spokespersons.

We celebrated World AIDS Day by ... okay we didn't celebrate World AIDS Day. This is our third WAD (as I like to call it) in Botswana and I think we're jaded enough to know better than to attend an event. Lots of money spent, no behaviors changed, no infections prevented, nobody receiving care or treatment because of it.

However, I did want to point people to this essay by Mpho Mogodi, who was my neighbor in the caravan at BOTUSA until she left to pursue her MPH at Johns Hopkins. She raises excellent points about PEPFAR and the need for capacity building. It's one of those really tough issues that have no easy answers. Very good questions that need to be considered and especially approprite to this year's theme "Leading the Fight." There are also really good links and articles on the JHSPH World AIDS Day website that you should check out.

Treatment

There was a great quote by Botswana President Festus Mogae in The Voice last Friday that should be put on the wall of everyone working with HIV/AIDS: “Priority number one is prevention; priority number two is prevention; and priority number three is prevention.” Continue reading below to access the entire article.

Abstinence

The Freakonomics Blog had an interesting comparrison of South Africa's ridiculous driving exam the failure of abstinence-only education in the states. Even if you support abstinence-only education on moral or other grounds, the approach just isn't working--so why keep funding it? See also: D.A.R.E. Continue reading below to access the entire article.

Another interesting article about AIDS prevention in the Washington Post. I came across the link on PSI's website (the article was published Nov. 1). Can't say enough here about the importance of prevention, but man is it difficult! There are low tech options (condom use, partner-reduction, abstinence) but for these to work it requires behavior change on the part of those who could are or could become infected. (Not to mention the people who are high risk but don't recognize their behavior as being risky.) In addition, one thing Brian and I talk about frequently is how much more succesful medical/clinic interventions are in Botswana than interventions using NGOs and that require personal behavior change. This is definitely influenced by the wealth of the Government of Botswana and their ability to provide unparalleled services to its citizens. Anyway, very interesting article Check out the link above to read the article in full.

I know that we've mentioned the Nata Village Blog here before and couple of times. It's a project by our good friend Melody and others in her village where they share stories about the village and raise funds for various HIV related needs. I stay up to date on the blog with the RSS feed and had to share their most recent successes:

A couple of weeks ago the clinic in the village received a fetal heart monitor thanks to the generous donations of a couple in Hong Kong. What spurred me to share this is Melody's post from yesterday about using the monitor for the first time. It literally brought tears to my eyes. In Botswana women do not normally get to hear the heartbeats of their babies they're carrying. There's just not the technology out in the clinics to do it. (And there's definitely no way to get a sonogram at the mall.) Can you imagine this woman's delight to be able to hear her baby's heart beating? I can only imagine, but seriously, it must be a miracle for her.

Another miracle ... they just got a donation of $20,000 from a group of people (most of whom have South African ties) and an anonymous donation of $6,000. As Melody says "That's U.S. dollars!!" The money will go so far here and the best part is that 100% of it will go directly to helping the people in Nata. How cool is that?

I know that we've mentioned the Nata Village Blog here before and couple of times. It's a project by our good friend Melody and others in her village where they share stories about the village and raise funds for various HIV related needs. I stay up to date on the blog with the RSS feed and had to share their most recent successes:

A couple of weeks ago the clinic in the village received a fetal heart monitor thanks to the generous donations of a couple in Hong Kong. What spurred me to share this is Melody's post from yesterday about using the monitor for the first time. It literally brought tears to my eyes. In Botswana women do not normally get to hear the heartbeats of their babies they're carrying. There's just not the technology out in the clinics to do it. (And there's definitely no way to get a sonogram at the mall.) Can you imagine this woman's delight to be able to hear her baby's heart beating? I can only imagine, but seriously, it must be a miracle for her.

Another miracle ... they just got a donation of $20,000 from a group of people (most of whom have South African ties) and an anonymous donation of $6,000. As Melody says "That's U.S. dollars!!" The money will go so far here and the best part is that 100% of it will go directly to helping the people in Nata. How cool is that?