Routine Testing Helps Botswana Track the Spread of AIDS

Voice of America, 1/26/2006

The World Health Organization estimates that less than 10 percent of Africans with HIV/AIDS know they are infected.

This -- despite decades of public education campaigns. WHO officials say such is the case in Botswana, which is estimated to have a high rate of infection.

In order save lives, AIDS treatment is free. But before people can be treated, they must be tested, and many are afraid to go for voluntary testing.

The WHO says as a result, the number of people receiving treatment is less than expected.

Three years ago this month the government came up with a new policy of routine testing in clinics.

Segolame Ramotlhwa is operations manager for the national HIV/AIDS treatment program known as MASA, or New Dawn.

He told VOA’s Ruby Ofori that the new program does not violate patients’ rights: “When patients come to our health facility all of them are offered and then if they agree to the test then they are tested. So it’s not like anybody is forced. ”

Mr. Ramotlhwa said as a result of routine testing more people are receiving anti-retroviral drug therapy.

“An important step towards fighting the epidemic is for people to know their HIV status. When they know their HIV status they’re somewhat empowered because now they know what they can do, and there’s something that the state can do for them.”

Source: VOA News.com

Muddling the message- VCT

by Kristin Palitza, Mail & Gaurdian, 24 January 2006

South Africa- Patience Mavata counsels an HIV/Aids support group at the Ikhaya Lobomi hospice in the Valley of a Thousand Hills in KwaZulu-Natal.

Voluntary counselling and testing (VCT) services are meant to help HIV-positive people cope with the disease, but some counsellors are doing more harm than good, particularly in KwaZulu-Natal.

Nurses, NGOs and Aids activists in the province say many HIV-positive patients could live healthier and longer lives if provided with better information about the virus and their treatment options.

Instead, they say, the VCT process leaves many feeling helpless and adrift.

Patience Mavata is a nurse who runs the Ikhaya Lobomi Aids hospice in the Valley of a Thousand Hills in KwaZulu-Natal, the province with the country’s highest HIV-infection rate, at 36%. She says many counsellors continue to tell patients that HIV is a death sentence.

“People lose hope because counsellors are so negative... counsellors kill people’s spirit.” And as a result “people die earlier than they should due to emotional stress,” she claims.

Mavata often admits patients to Ikahya Lobomi who have gone through the VCT process at public hospitals or clinics. They tell her that they were given their test results but no medical or nutritional advice.

Many are sent home knowing they are HIV-positive but not knowing what to do next.“We are concerned about the quality of VCT,” says Sifiso Nkala, Treatment Action Campaign (TAC) provincial coordinator in KwaZulu-Natal.

“Bad counselling does not only discourage people, it isolates and creates a stigma.” Nkala says many HIV/Aids counsellors do not have appropriate referral systems in place to help HIV-positive people access support groups, manage opportunistic infections or understand anti-retroviral (ARV) treatment.

And, he adds, counsellors often have insufficient medical knowledge about treatment options and side effects of ARVs. Poor quality HIV/Aids counselling might also be one of the reasons for the low uptake of VCT services.

In the past four years, only 850 000 South Africans out of a population of almost 45-million have been tested for HIV, according to the United Nations Development Programme. The problem is not unique to South Africa -- the World Health Organisation (WHO) estimates “fewer than 10% of people in African countries at the epicentre of the pandemic know their status”.

Mavata says counsellors often fail to inform patients about the need for CD4-count testing or how and when to access ARV therapy. As a result, many HIV-positive people go for CD4 testing too late for ARV therapy to be effective. HIV-positive persons with a CD4 count between 50 and 200 are eligible for ARV therapy.

If a CD4-count has dropped below 50, the immune system is too weak to deal with the powerful drugs and doctors will try to boost patients’ CD4 count with better nutrition or antibiotics. But many counsellors are unable to provide any useful nutritional information.

“Counsellors use the term ‘balanced diet’ but many are unable to explain what it truly means,” says Zanele Mjoka, community development facilitator at the National Association of People Living with HIV/Aids (Napwa) in Durban.

She says she often receives calls from distressed and hopeless clients who said they had not found pre- and post-test counselling, particularly that offered in public hospitals, to be helpful.

Mjoka believes staff shortages and heavy workloads are largely responsible for the poor quality of counselling. She says that in order for counselling to be done properly, counsellors should see no more than five clients per day.

“Otherwise they rush people through,” she explains. In public hospitals and clinics, counsellors deal with 15 to 20 patients a day. She adds that the Department of Health needs to ensure counsellors are debriefed on a regular basis to deal with the emotional strain of their jobs.

Many public sector counsellors receive insufficient training and the 10-day training course offered by the Department of Health is too short to prepare them adequately for the job, says Mjoka. According to the health department’s website, it employed 887 counsellors at 474 VCT sites across the country in March 2002, but does not provide any updated numbers.

Department of Health spokesperson Daphney Lebethe said the department’s database showed that about 12 000 counsellors had been trained, but could not provide a breakdown per province. She said the department also provides refresher courses for practicing counsellors at provincial, district and local level.

Poor quality counselling also increases the risk of mother-to-child transmission of the virus. Research conducted last year by the Medical Research Council, Health Systems Trust and the University of the Western Cape found that counsellors failed to communicate all the facts women needed to make an informed choice about infant feeding and to practice that choice safely.

The study found that only a third of the women who chose to use milk formula were given instructions, and none of the women who chose exclusive breastfeeding could define what the term meant.

Research has conclusively shown that, apart from the actual process of birth, the highest risk of HIV transmission comes from combining breastfeeding and formula feeding.

“Counsellors have the power to influence the life of an HIV-positive person in a very positive or very negative way,” says Mavata.

Source: Mail & Gaurdian online

Botswana's AIDS program confronts stigma, fear- Drugs provided free, but getting people to agree to be tested is hard

Associated Press, January 5, 2006

GABORONE, Botswana (AP) -- When Botswana first offered free AIDS treatment, health authorities in one of the world's most infected countries braced for a rush. It didn't come.

Most people were still too afraid to get tested for the deadly scourge.

The startling reluctance to seek help in one of the few African nations able to provide it prompted a radical rethink of how testing is done here. An HIV test is now offered as a routine part of any medical visit.

In most countries, patients are left to ask for a test themselves, then put through extensive counseling to prepare them for the outcome. But despite decades of education campaigns, World Health Organization officials estimate fewer than 10 percent of HIV-infected people in the African countries at the epicenter of the pandemic realize they have the virus that causes AIDS.
Botswana's decision 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," countered Segolame Ramotlhwa, operations manager for the national treatment program dubbed Masa, or New Dawn.

He argued 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 adults.

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

Dr. Howard Moffat, medical superintendent at Princess Marina Hospital in the capital, Gaborone, said people who were not sure they wanted to know their HIV status often emerged from counseling determined not to be tested.

"I think the medical profession itself ... played a major role in creating this fear of AIDS and this quite irrational reluctance to be tested," he said.

Waiting too long 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 percent of the 1.7 million population now know their status.

If the outcome is negative, a health worker will briefly reinforce the importance of staying that way. If it is positive, the patient will receive help to manage the condition and treatment when needed.

Most people only see a doctor when their symptoms are 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 daughter, now a 7-year-old. Both are now on 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," said the fragile-looking 27-year-old, as she waited in a daylong line for her medicine.

Much of the emphasis on voluntary testing and counseling came from HIV's early association in the United States with homosexuality, which is widely taboo in sub-Saharan Africa, home to more than 60 percent of the estimated 40 million infected globally. This became the international standard, even though HIV is now overwhelmingly a heterosexual disease that killed 2.4 million on this continent last year alone.

Life-prolonging anti-retroviral medicines that have turned HIV into a manageable chronic condition in wealthier countries remain out of reach for all but a handful in Africa. They are expensive, and most countries lack the medical staff and infrastructure to dispense them widely.
Botswana was the first country to offer free medicines to all who need them in 2002. It now has half the estimated 110,000 in immediate need on treatment.

Botswana rights activists agree on the urgency of reaching the other half, but worry many consent to a test without being prepared. There is a cultural reluctance to question doctors here.
A study of antenatal clinics in Botswana's second city, Francistown, found 90.5 percent of women tested for HIV in the first three months of the new policy, compared with just over 75 percent in the last four months of the voluntary approach. Many, however, failed to return for their results.

"At the moment it seems like a numbers game, a total drive to get people to know their status. The question is then what?" said Christine Stegling, of the Botswana Network on Ethics, Law and HIV/AIDS. "I have a feeling that what is happening is health care providers are getting out of communicating meaningfully with their patients."

The new approach is 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 program.

Stegling believes testing numbers are going up in part because people are starting to see the effects of treatment.

WHO and UNAIDS now encourage routine testing in all HIV-prevalent areas where anti-retrovirals are available. But for millions, a positive result remains a death sentence.

Source: CNN.com