HIV EPIDEMIC IN BOTSWANA; OVERVIEW, TRENDS, CHALLENGES AND SUCCESSES. BY DR. AKEEM SALAWU (MBBS, MPH)

Demography of Botswana Botswana is a landlocked country in southern Africa. It is bordered by South Africa, Namibia, Zambia and Zimbabwe. Its capital city is Gaborone. Other major cities include Francistown, Lobatse and Selebi-phikwe. Land area is 600,370km² with a population of about 2million and annual growth rate of -0.4% for the year 2005-2010.(UN population division) Major language is Setswana. Five major ethnic groups are identified; Basarwa; Bakalanga; Bangwato (majority), Baherero and Barolong, all with unique cultural sexual practices. Settlement- Traditionally Batswana have 3 abodes: principal home in the village; the cattle post ; and the lands . Some have a fourth home in an urban area.

Cultural Dimension of Sexuality among the ethnic groups Basarwa- woman could have sex with any man as long as they leave a spear at the door to alert other men of their presence. Multiple sexual partner is socially acceptable. Bakalanga-Nkazana (means “small house”) is usually younger female sibling of the wife. Bangwato- Mantsala; playful sex with a blood or ethnic cousin. Condom not culturally acceptable. Baherero- ‘Otusira’ (replacement of the dead ones); girls from the deceased family will be available for unprotected sexual encounters with relevant extended-family male members. Barolong- ‘Seantlo’ (wife/husband inheritance); widow or widower marries a sibling of the deceased husband or wife. There are also positive cultural practices.

Overview of and epidemiological trend of HIV in Botswana. Botswana’s first HIV case was reported in 1985 Transmission is basically via heterosexual and maternal to child. It spread like wild fire in the late 1990’s by 2001 the total number of case stood at 280,000 and 350, 557 in 2009. Prevalence accord. to annual ANC sentinel survey was; 36.2%(2001); 37.4%(2003);32.4%(2005); 32.5%(2009). Gen population 17.1%(2004)17.6%(2008). More females affected (20.4%); males 14.2% (BAIS,2008) Age group most affected females 30-34, males 40-44yrs (2008) Prevalence is highest in the northern and north-eastern part; along the border with Zimbabwe, South Africa and Zambia . The epidemic is however leveling off (at around 17%) but the impact is still felt.

Challenges of HIV prevention in Botswana MCP- key driver of HIV transmission in Botsw. 23% (2003); 11.2% (2009) of women and men aged 15-49 yrs had sex with >1 partner in the last 12months (BAIS III) High mobility- one of the most mobile pop. in the world (MoH,1997). Spreading the virus to even the remotest areas. High alcohol consumption- result from a population study shows that 31 % of men and 17 % of women met the criteria for heavy drinking. (Weiser 2005). GBV- The lifetime and past year prev. of IPV was estimated at 49.7% and 21.2% respectively. STIs including HIV (25%) TB- most common cause of death in HIV +ve people in Botsw. Prev. 60-80% among HIV +ve individuals. Emergence of MDR (196 cases); XDR 5cases Inadequate resources; human and financial. Others; stigmatization; adherence to ARV; dev of resistance. MCP= Multiple Concurrent Partner; GBV= Gender-Based Violence

Achievement/Successes and current interventions Good political support- gov. declared HIV/AIDS a national emergency in 2001. Spent $165.0 m(2005); and over $203.8m(2007) on various programs and treatment. Free ARV- rolled out in Jan. 2002. By 2009, 89.8% (≈145,190) of those requiring ARV were put on treatment. Reduction of MTCT- introduced in 1999. Achieved >95% coverage since 2006. Transmission down from b/w 20%-40% to 3%. Reduced mortality- Deaths (of adults and children) due to AIDS was 16 000 (2001); 8 732 (2008). (BIAS III,2008) Success complemented by foreign partners; American gov. Harvard school of public health, UPPEN etc Current prevention/intervention Safe male circumcision; rolled out as a national program in 2008 and targets about 500,000 males over 5 yrs. Intervention on reduction/discouraging MCP.

References UNAIDS 2008. Country situation; Botswana Botswana country report 2010 on progress of the national response to HIV/AIDS UNAIDS 2007, Progress and challenges for Botswana Ntseane PG 2003. Cultural dimensions of sexuality; Empowerment challenge for HIV/AIDS prevention in Botswana UNAIDS/WHO/UNICEF 2008. Epidemiological Fact Sheet on HIV and AIDS IN Botswana Weiser SD et al 2005. A Population-Based Study on Alcohol and High-Risk Sexual Behaviors in Botswana”. CSIS 2004. Botswana’s Strategy to Combat HIV/AIDS Lessons for Africa and President Bush’s Emergency Plan for AIDS Relief