Fighting Back Against HIV in Botswana

JIM LEHRER:

Now Elizabeth Farnsworth's third report on the AIDS crisis in Africa. Last night, she told of Botswana's prevention efforts; tonight she reports on the government's efforts to get anti-AIDS drugs to its people.

ELIZABETH FARNSWORTH:

Among these tumbling rocks are precious diamonds. They're being processed at Botswana's largest diamond mine, which is highly mechanized and dependent on skilled labor. In the last decade, HIV/AIDS has become a growing threat here. Close to 1/3 of the employees at the diamond company Debswana, which is half-owned by the government, have tested HIV positive.

ELIZABETH FARNSWORTH:

It must be really hard to work so closely with people and have so many people sick.

THATO GALEBOU, Mine Worker:

It is. It's very hard, and to some extent you have to try to encourage them and accept them. When we first heard of AIDS, there was stigma that people are going to die and all of that. At least people are now beginning to accept it.

ELIZABETH FARNSWORTH:

Diamonds from mines like this are crucial to Botswana's economy, and as more and more workers ended up sick, Debswana decided to act. In early March, it announced that company doctors like Kobus Erasmus would begin to provide the full package of life-saving drugs called anti-retrovirals which have saved millions of lives in developed countries. The mining company would pay 90% of patients' costs.

DR. KOBUS ERASMUS:

We're going to be in trouble in this mine if we don't treat them. Apart from that, I think it's our duty to treat these people because they're all loyal workers and it's a first for Southern Africa in any case. We're the first company that's going to treat HIV patients on a large scale, as we're planning to do.

ELIZABETH FARNSWORTH:

Other businesses in this country are losing workers too. With its diamond wealth, Botswana has built one of the most successful economies in Africa; but now — with 36% of its adult population believed to be HIV-positive — the country is facing a potentially catastrophic shrinking of economic life. Dr. Banu Khan coordinates the government anti-AIDS programs.

DR. BANU KHAN, National AIDS Coordinating Agency:

We have managed our country well. We have had no civil strife. We have used most of our resources to develop the infrastructure to benefit the people in terms of social services like education and health, and all these hard won gains are being reversed by the epidemic.

ELIZABETH FARNSWORTH:

To halt the reverse of those gains and to save lives, Botswana's president, Festus Mogae, announced in March that the government — like the diamond company — would try to provide anti-retrovirals to all who need them — regardless of ability to pay.

PRESIDENT FESTUS MOGAE, Republic of Botswana: I have created a National AIDS Council which is a multi-sectoral national committee on HIV/AIDS; and we are in the process of creating multi-sectoral committees for every town, in every village and every suburb.

ELIZABETH FARNSWORTH:

Well-supplied hospitals and adequate foreign reserves make it easier for Botswana than other African countries to provide the drugs. But even here — where the annual per capita income is $3,700 a year — high for Africa — many people remain poor. Few could afford the $10,000 a year that anti-retroviral drugs cost in the developed world. Botswana can provide the drugs partly because an international campaign by AIDS activists to get companies to reduce prices has had an impact.

In recent months, drug companies have been negotiating radically lower prices with African governments. Bristol Myers Squibb executive Vice President John McGoldrick was in Botswana in late March.

ELIZABETH FARNSWORTH:

Can you tell us anything about the status of your negotiations with the Botswana government?

JOHN McGOLDRICK, Bristol Myers Squibb:

Well, I think our talks with the Botswana government should remain between us and the Botswana government, but essentially, they are very clear — we tried to be very transparent. Our medicines will be sold at below cost. For our two medicines today that's around a dollar a day.

ELIZABETH FARNSWORTH:

The MERCK drug company is offering two of its drugs free. Donald de Korte was the company's CEO in South Africa before coming here to oversee a joint $100 million MERCK- Gates Foundation Project.

ELIZABETH FARNSWORTH:

You've known about HIV/AIDS for a long time. Why'd it take so long for the companies to do this?

DR. DONALD DE KORTE, MERCK/Gates Foundation:

I think it took awhile to realize that as a company you have also responsibilities to the world. But I'm really convinced that now the decision has been made that these drugs will get available widespread, very rapidly.

ELIZABETH FARNSWORTH:

Dr. Banu Khan said drugs prices are no longer the key problem in Botswana.

DR. BANU KHAN:

It's not just the price of drugs. It's the over-all package, the testing for viral load, for the CD4 count, these are tests to find out how bad one is infected, as well as how good is your immune system… and these are costly and also the training of health care workers to prescribe these drugs. So that package in the end ends up more expensive than just the cost of drugs.

ELIZABETH FARNSWORTH:

And Botswana can't do it alone, the president said.

PRESIDENT MOGAE:

The health budget is growing by leaps and bounds. I think it's maybe three or four times what it was three years ago, and we were under no delusion that in another 3 years, it will be double or triple what it is today. Without help, we couldn't possibly manage.

ELIZABETH FARNSWORTH:

Help has come from the Harvard AIDS Institute, among others. These Harvard doctors — working in partnership with the Botswana government at the public hospital in Gabarone — are doing research on the type "C" HIV virus, the one prevalent here. They're also providing clinical care to AIDS patients. The goal is to help develop models for providing anti-retrovirals safely

DR. RICHARD MARLINK, Harvard AIDS Institute:

With the partnerships that the people from Botswana have created, they really are on the threshold of showing the rest of Africa and the world how to prevent and how to treat this virus in an African setting.

ELIZABETH FARNSWORTH:

This patient is a candidate for the anti-retroviral drugs, which target the particular form of virus to which HIV belongs.

DR. RICHARD MARLINK:

She has a CD4 count –the level in her blood of her immune cells that are critical — she has a CD4 count of four. Four is about as low as you can get, which means another infection, a severe infection, is going to happen very soon.

DR. RICHARD MARLINK:

Are you having any problems with those two tablets?

DR. RICHARD MARLINK:

So we've looked into her home life and what's the situation — how can we boost her nutrition mainly because to get on the anti-retrovirals you've got to have a strong home life and support system to take the drugs regularly.

DR. BANU KHAN:

The human immuno-deficiency virus is a clever one, and if you don't correctly administer the drugs in the right combination, and you don't counsel people to take it correctly and for a long time, then the virus is able to develop resistance and the drugs are not that effective.

ELIZABETH FARNSWORTH:

Dr. Khan said the government is hoping to find effective but simple drug regimens that will work for people who don't always have access to clean water or three meals a day. In the developed world, anti-retroviral drug regimens can be very complicated. Dr. Tom Kenyon represents the U.S. Centers for Disease Control — which has an $8 million project in Botswana.

DR. TOM KENYON, Centers for Disease Control: There are simpler regimens that Botswana is going to need to look at — perhaps once daily dosing or twice daily dosing and that can be directly observed. But yes, it's going to require enormous effort in terms of patient education and helping patients to adhere to therapy. It's difficult treatment.

ELIZABETH FARNSWORTH:

A high tech laboratory is under construction in Gabarone, which will have the capacity to analyze how patients on anti-retrovirals are doing. It's funded by the government and Harvard with help from Bristol Myers Squibb. But still more facilities will be necessary.

DR. TOM KENYON:

We just did a laboratory assessment a few weeks ago to see what infrastructure should be in place — for example — for viral load testing; you need costly equipment on the order of $25-$30,000. That would be put in strategic centers, not certainly in every hospital, but perhaps in a couple of referral centers.

ELIZABETH FARNSWORTH:

The partnerships in Botswana may serve as models for other African countries.

PRESIDENT MOGAE:

The Bill Gates Foundation and the MERCK Company have said that if the programs on which we have embarked–that if it works in Botswana, if it appears to work, they will be willing to consider extending them to some of our neighbors, which will be a good thing.

ELIZABETH FARNSWORTH:

Harvard's Dr. Marlink hopes to extend the programs even to very poor countries, like Malawi.

DR. MARLINK:

There are problems in Malawi that are going to be much harder to overcome, but it's not impossible because the medications can be given even in those difficult situations with low infrastructure, poor clinics, etc. We need a fund of money that can move quickly to build a clinic, to build a laboratory, to ensure that the drugs have a distribution system. We have to look hard at ourselves as to why that sense of emergency is not manifesting itself into dollars and effort.

ELIZABETH FARNSWORTH:

Already in Botswana, the promise of treatment is changing behavior. At the diamond mines, 30 percent more employees have been tested for the HIV virus since the Debswana Company announced it would offer the drugs almost free. Hope of treatment encourages people to agree to be tested, and testing is considered crucial for prevention. And even as efforts to treat people get underway, prevention remains the highest priority here.

Francistown AIDS activist Patricia Bakwinya and other volunteers continue to visit bars to show people how to prevent HIV using male and female condoms. And in nearby Tutume, young health workers continue to visit schools to keep the next generation HIV-free. These and other volunteers — along with the doctors and nurses treating the sick -are the heroes of Botswana's AIDS epidemic; and now at least they can offer some hope for those who are infected.

JIM LEHRER:

Tomorrow night we'll report on one of Africa's most successful AIDS prevention programs; it's in the nation of Senegal.