Why Botswana is losing the HIV/AIDS fight

Living as an openly gay man in socially conservative Africa is hard enough, but Edwin Cameron, a South African Constitutional court judge went even further. He was the first-and remains the only-senior public official in Africa to reveal his HIV status. Former South African president Nelson Mandela appointed him a Supreme court judge and called him “South Africa’s new hero.”

As president, Kgalemang Motlanthe appointed him judge of the Constitutional court. “Mandela recognised that after apartheid, AIDS was a challenge and that I took a leadership role,” remembers Justice Cameron, a Rhodes scholar as he settles on a small but modest chair at Gaborone International Convention Centre.

As a human rights czar, Justice Cameron had been invited to officiate at the Botswana Network for Ethics, Law and HIV/AIDS (BONELA) – an AIDS watchdog 10-year anniversary but was confronted with news that legislators here are debating a controversial Public Health Bill, which threatens to reverse gains made in ending stigma.

He had faced many a hurdle and lived silently for 13 years following his diagnosis on “Friday 19 December 1986.” But when a Durban woman, Gugu Dlamini who had gone public with her status was stoned to death, Cameron knew that his silence would reinforce stigma and that it was time to “normalise” the epidemic. “Everyone struggles with internal stigma,” he says and explodes with details on how individuals condemn themselves and take in feelings of rejection. “Silence reinforces stigma. It’s a vicious circle.”

This circle can only be broken by presence of strong political leadership, which unfortunately lacks in Botswana. He would have been surprised that after some 28 years of intense medical research on its virology, an elected legislator and cabinet minister can giggle in wonder as to whether his colleague has been infected by HIV. Lebonaamang Mokalake later apologised to Member of Parliament for Chobe, Gibson Nshimwe during a fierce debate on the Public Health Bill, which seeks to penalise anyone who resist HIV test.

Unlike Mmampe Phalalo, an Oodi woman whose seven-year daughter was diagnosed with HIV in 2005 after transfusion of contaminated blood at Deborah Retief, Justice Cameron contracted the disease through unprotected sex with another man. “I am a gay man and I am proud,” he would say to a seemingly liberal and tolerant audience. After 46 years of independence, Botswana remains fiercely conservative and homophobic. Even former president Festus Mogae has risked his popularity in his call for recognition of gays and lesbians.

Justice Cameron regrets that while Botswana political leadership during Mogae’s years worked hard to address the epidemic, South Africa was in stark denial. “My president (Thabo Mbeki) re-stigmatised the disease at a time when Mogae was looking for retreatment for all.” Currently six million South Africans are living with HIV. Both Mokalake and the Public Health Bill, which is at Committee Stage, seem to reverse gains made by Mogae in helping fight the epidemic. Justice Cameron avoids details of the discussion obviously wary of not criticising the leadership on a matter he has not studied. The Bill will effectively penalise anyone who resists HIV test.

In principle, Justice Cameron believes this is utterly wrong. “I will tell you why coercion does not work,” he says as he settles down. “I have dedicated my life to human rights law. If the Bill violates those precincts, then it is wrong in principle and wrong in offending against rights.” In its current form, the Bill also empowers doctors to test clients without their knowledge and forces medical practitioners to report HIV cases to ministry of health officials.

The Bill will also force people living with HIV to tell whomever they have sexual relations with about their status. AIDS watchdog, Botswana Network on Ethics, Law and HIV/AIDS (BONELA) is “deflated” by the seemingly barbaric Bill. “As to why that is government business, I can’t tell. I know what the Bill means to my people and doctors who have not been consulted,” quips BONELA director, Uyapo Ndadi. But Justice Cameron has enough charm to influence even the extreme fish-out-of-water AIDS denialist and stigmatist.

He has been to Oxford University to research on the epidemic and examine the denialist tendency as supported by Mbeki. He returned with a firm conclusion: African elites have failed their people. “Because they make legislation that coerce people to disclose their status. You got to get people to agree…” he argues, adding that African leaders’ silence and inaction, reinforces stigma.

Over 1.9 million Africans acquired the virus in 2011 alone. He believes any law that coerces the public to act in a certain way desired by the state is wrong in principle. Currently 17 out of 100 people are living with HIV in Botswana, a landlocked poorly diversified mineral-led country.

This translates to around 200 000 people, a population of Gaborone. Dr. Eva Avalos a physician and former clinical advisor at the Department of HIV/AIDS Prevention and Care believes the number is likely to increase (to 300 000) as the clinical medical system has gaping holes.  Princes Marina, the largest hospital in the country is in critical shortage of clinical health specialists, according to Dr. Avalos. “There is no counselling, no psychologists, a doctor sees 50 patients a day and there are no social workers,” say Dr. Avalos who was tasked with caring for critically ill AIDS patients.

She adds that 25 percent of AIDS patients at Marina have not tested for the dreaded disease. Permanent Secretary in the Ministry of Health, Dr. Kolaatamo Malefho agreed that Botswana faces challenges of shortage of resources, but explained that lay counsellors have been used to supplement clinical psychologists. “We started from scratch 10 years ago. We have just started to build a team for counselling,” he said, adding that a lot of investment is placed in improving counselling.

“Our nurses are multi-skilled they stay the longest with patients unlike doctors.” World Health Organisation has emulated Botswana guidelines on HIV, says Dr. Malefho.Stanley Monageng, a retired nurse and an AIDS activist is a living testimony of Botswana’s public health failure. In October this year, Botswana experienced an acute shortage of one of the life-giving Antiretroviral. Monageng was forced to travel long distances, only to receive less potent medication.

He had developed resistance by the time he received his Alluvia. He is teary as he agrees with Justice Cameron that sustainability of treatment to HIV will not be achieved if the state forces people with draconian legislation. “Parliamentarians are not interested in our health,” he says.

Monageng is an HIV patient on first line medication, which, according to Dr. Avalos is cheaper (at US$365 per month). Currently five percent of Batswana patients have developed resistance to first line medication due to interrupted treatment, contrary to South Africa’s 25 percent, according to statistics provided by Dr. Avalos. However there are those like Dr. Joseph Makhema, Chief Executive Officer at Botswana – Harvard Institute who remains optimistic that Botswana is on the right track in the fight against AIDS and that the Public Health Bill should be debated rationally.

“What is important is to get people to test early,” he notes to murmurs of agreement. Botswana spends around three percent or P3 billion of its Gross Domestic product (GDP) towards the fight against HIV/AIDS. Dr. Makhema shares Mogageng and Justice Cameron’s views that educating people will address problems associated with stigma.

“The Bill is important, but let’s consult and be constructive in order to protect public health resources and remain sensitive to human rights and privacy,” he advised. Another physician, Dr. Themba Moeti is of the view that treatment sustainability could be a reality if patients commit to the drugs.

“ARV programmes have had tangible results, they have reduced mortality by half and saved 53 000 lives. At the end I ask Justice Cameron if his sexual orientation and HIV status influence some of his decisions in court. Except to prevent discrimination, HIV is not like skin colour, you need to be neutral,” he says as he pleads with Botswana elites to normalise HIV.

“If 17 percent of the population is positive, it goes to imply that 17 percent of cabinet or parliament may be positive.” Hopefully Mokalake gets it.