Botswana adopts radical approach in HIV testing

When Botswana first offered free Aids treatment, health authorities in one of the world’s most infected countries braced for a rush of patients. It didn’t happen.

It turned out that most people were so afraid of the deadly disease, and the frequent social ostracism, that they didn’t want to know whether they were infected.

That reluctance to seek help in one of the few African nations able to provide it prompted a radical rethinking of how testing is done there. Now, HIV tests are offered as a part of any medical visit.

In most places, patients are left to ask for a test themselves, then put through extensive counselling to prepare them in case HIV infection is found. But despite decades of education campaigns, the World Health Organisation estimates less than 10% of infected people in the African countries at the epicentre of the Aids pandemic realise they have the virus.

The decision of this southern African nation to start routine testing initially caused alarm among international health advocates, who worried that patients’ rights to confidentiality and informed consent would be compromised.

“I think the first right of a human being is to be alive. All other rights are secondary,” counters Segolame Ramotlhwa, operations manager for the national treatment program known as Masa, or New Dawn.

He argues that confidentiality was being confused with secrecy, making doctors reluctant to even suggest testing for a disease that has infected more than a third of Botswana’s adults.

Doctors there believe pulling patients aside for special counselling is intimidating and helps fuel the stigma that keeps patients from seeking help.

“In fact, we found that people who had not made their minds up quite often were definitely against it once the pre-test counselling was done,” said Dr Howard Moffat, medical superintendent at Princess Marina Hospital in the capital, Gaborone.

“I think the medical profession itself … played a major role in creating this fear of Aids and this quite irrational reluctance to be tested.”

Since the beginning of 2004, Botswana has treated HIV tests like any other medical procedure.

Patients have the option to refuse, but doctors say most don’t. They estimate up to 35% of the country’s 1.7 million people now know their status.

If the test proves negative for infection, a health worker delivers a brief message on the importance of staying that way. If the test is positive, the patient gets help to manage the condition and treatment when needed.

Most people see a doctor only after their symptoms become severe, by which time it may be too late. It takes three to four times more resources to save someone who arrives on a stretcher than someone who is still on their feet, Ramotlhwa said.

When Kelatlhilwe Segole was pregnant, she was not offered an HIV test and unwittingly passed the virus to her seven-year-old daughter. Both are now in treatment, but her husband refused to be tested until he was in a wheelchair.

“I kept telling him, he will die because of not knowing his status,” Segole, a fragile-looking 27-year-old, said as she waited in a day-long line for her medicine.

WHO and UNAids now endorse routine testing in all HIV-prevalent areas where Aids drug “cocktails” are available.

Much of the emphasis on voluntary testing and counselling came from Aids’ early association in the United States with gays.

That gave the disease an added taint in Africa, where homosexuality is widely taboo. But Aids is overwhelmingly a heterosexual disease in Africa, home to more than 60% of the world’s estimated 40 million infected.

Life-prolonging medicines that have turned HIV into a manageable chronic condition in wealthier countries remain out of reach for all but a handful in Africa. The drugs are expensive, and most countries lack the medical staff and infrastructure to dispense them widely.

A diagnosis of HIV often is a death sentence, experts say. Last year alone, 2.4 million people died of Aids causes in sub-Saharan Africa.

Botswana was the first country in Africa to offer free medicines to all who need them in 2002, and the government says half the estimated 110,000 people in immediate need are being treated.

Rights activists agree on the urgency of reaching the other half. But they worry that many people consent to an HIV test without being prepared psychologically, noting there is a cultural reluctance to question doctors.

A study of prenatal clinics in Botswana’s second city, Francistown, found 90.5% of women consented to HIV tests in the first three months of the new policy, compared to just over 75% in the last four months of the system requiring patients to volunteer for a test. Many of those women, however, failed to return for their results.

Christine Stegling, of the Botswana Network on Ethics, Law and HIV/Aids, believes testing numbers are going up because people are starting to see the effects of treatment, not just because they are offered tests more often.

The new approach is also more likely to reach women, who are more frequent visitors to health services because of pregnancies. Men continue to be underrepresented in Botswana’s treatment programme.

“At the moment it seems like a numbers game, a total drive to get people to know their status. The question is then what?” Stegling said. “I have a feeling that what is happening is health care providers are getting out of communicating meaningfully with their patients.”