HIV in Botswana: The Case for an Aggressive Approach

As I’ve mentioned here before, I’m in Botswana to work at a pediatric AIDS clinic. Work is going much more slowly than you might imagine. But I’ve spent much of the downtime of the past month learning more about just why what my corner of the clinic does, providing psychosocial support to teenagers, is so important.

First some background on HIV/AIDS in Botswana, which is the second hardest-hit country by the epidemic after Swaziland. Currently, about 17.6% of the population is infected with AIDS, though a decade ago nearly 40% of adults were infected. Compare this with the recent news that Kenya’s HIV prevalence has dropped from 7.2% to 5.6% in the last five years. I often find myself thinking about the peak years of the epidemic in much the same way I think about years of conflict or genocide in Uganda and Rwanda, with the societal impacts (particularly demographics and the long-term effects on the workforce, education system, family structures, etc.) playing out in ways that remind me greatly of post-conflict societies. HIV/AIDS isn’t just a medical problem, it’s a social and economic problem as well.

The government has been highly effective in curbing the devastating effects of the disease. In the early days of the epidemic, infection often resulted in death within a few years. Unity Dow and others talk of social life being overrun by funerals in 2004 and 2005 to the point that people couldn’t keep up, that traditions around burial and ceremony had to be adjusted to accommodate the surge. Life expectancy was under 40 years in the early 2000s; now it is 53. Thanks to the government’s work (in partnership with other organizations and companies) to end transmission of HIV by 2016, HIV testing is something you must now opt out of to avoid, anti-retroviral medications (ARVs) are widely available and covered by public healthcare, and prevention of mother-to-child transmission services (PMTCT) have caused a drastic drop in new cases in children (now only 4% of newborns get HIV from their mothers).

In fact, the government has been doing so well that people are starting to talk about redistributing funding. “These programs are great, but is it still the best allocation of limited resources?” Critical minds in development/aid work (always) want to know. Why pour more resources into eliminating transmission of HIV, an infection with which many people can live long, fulfilling lives, when there are other infectious diseases and rising levels of non-communicable diseases (NCDs) that kill lots of people and do not receive enough attention?

That is a question I likely would have posed before I got here. Not that it is a bad thing to try to stop HIV transmission, I would have hastened to ad, but hasn't there been so much progress over the last decade that we're reaching a point of diminishing marginal returns on investment? I still think there's a lot to be said for re-examining health spending priorities, but here is a non-exhaustive list of some of the points I'd now make in favor of continuing efforts on this front:

1. Children infected with HIV face a significantly higher likelihood of developmental delay than HIV-negative children. Those delays can, in some cases, cause them to slip through the cracks of Botswana’s education system. Not to mention the school they miss or work the adults miss to receive medical care. So not only has the previous generation’s working population been eroded, but also a portion of the current generation of youth is growing up unable to succeed academically or in the workforce.
   

   

   
   
2. Improving HIV/AIDS-related health systems strengthens more of the health network than just the HIV-related components, just as having HIV/AIDS makes you susceptible to a range of other health issues and often complicates treatment for other diseases (e.g. the rise of cancer in Botswana and other resource-poor countries is linked to HIV). The clinic I work in specifically targets HIV-positive children, but provides a broad range of services to them and their families. As fewer and fewer children are HIV-positive, I wonder whether the clinic will expand to adult HIV-positive patients or HIV-negative children. Overall, I expect the health infrastructure that has been put in place to combat the epidemic can be extended to cover more general health services.
   
   
3. Although life with HIV can be long and fulfilling, it’s not easy. Adhering to a strict daily drug regimen—taking your medicine at specific times of the day, with food—for the rest of your life is more difficult than it sounds, and non-adherence can allow the virus to develop resistance to your medications, which makes the disease more serious, for you and for society as a whole.
   
   

It’s this last point that’s most relevant to what I do. Following the implementation of PMTCT programs, the number of young children with HIV is diminishing and most infected youth are adolescents born pre-PMTCT (which was introduced in Botswana in 1999). And adolescents tend to have a hard time with adherence.

Adolescence is a difficult time for people anyways, with trying to prove yourself and establishing independence and rejecting authority and having insecurities and developing new relationships and being overexposed to narratives of what “normal” is—while still negotiating a sense of self to counter those narratives. Hyper-awareness of stigma and the opinions of others can tip the balance for adolescents grappling with issues of disclosure to their partners and others, of taking their medicine regularly when friends and dorm-mates are around, of wanting so badly to be “normal” that they play tricks with themselves (“maybe if I just don’t take my meds it will be like there’s nothing wrong”). These problems aren’t unique to HIV-positive youth.

I think there’s also a really interesting tension in adolescents between, on the one hand, the desire to live in the moment—with greater reward-seeking leading to greater risk-taking—and on the other hand, a growing appreciation of the idea of permanence, particularly among older adolescents. I think (though I’m no psychology expert!) it’s in late adolescence that people start to grasp what they can, and more importantly cannot, expect to change over the course of their lives and what it really means to have a medical condition that will be a part of them for the rest of their lives. And I imagine that can be a pretty scary, desperate place to be at times.

Last Saturday, over a hundred teenagers turned up to the clinic to hang out with other HIV-positive teens and do activities and hopefully learn something about how to have happy, healthy, fulfilling lives and (most importantly) to have a lot of fun. I’m responsible for planning these events every month, and it feels like a big task to shoulder—not because the logistics are difficult, but because I think about all the potentially dark things happening in their hearts and minds and wonder how to break through all that, to get them to healthy adulthood in day-long installations once per month.

Our co-facilitators for the day started off with some song and dance in the clinic lobby, coaxing the kids to mingle, then clap, then turn to their neighbors to say “you’re special”, then make some noise. I saw a girl of about fifteen roll her eyes at her friend. And somehow suddenly the entire room of 144 teenagers and volunteers was jumping and cheering and singing and waving their arms and bursting with impossible grins and in the deafening noise and exuberance, I swear you could feel the joy as a tangible force in the room. These kids were so full of life. I choked up; it was one of the most moving experiences I’ve had.

I don’t want these teenagers to get sick, don’t want them to feel they won’t be loved if they disclose their status, don’t want them to struggle with normality/identity/secrecy/insecurity any more than any other teenager does. And maybe they don’t, mostly – the small discussion group I joined talked about their biggest obstacles being stress over exams, just like any other teenager. But the facts are that adherence rates are significantly lower among adolescents and young adults than they should be.

I watch the teens elected to be leaders among their peers work magic bringing the teens together and taking responsibility to make sure things run smoothly, and I see kids turn up every Saturday for extra tutoring (and wait patiently for me to remember how to explain their basic chemistry problems), and I feel such fierce, affectionate admiration for them. They are what makes my being here worthwhile, and why I want to see what else Botswana can accomplish in HIV/AIDS prevention and treatment.

First impressions of Gaborone

Nearly four weeks into my stay in Botswana, I’m starting to feel like I’ve found my footing and am really getting settled. Unfamiliar pronunciations are starting to roll a bit more easily off the tongue, seemingly-identical intersections are becoming landmarks that help me build my mental map of Gaborone.

Work has been somewhat slow, but I am looking for projects to get involved in. When I’m not working, I’ve been filling my time with braais (barbeques), slowly improving my disastrous frisbee “skills”, camping, cooking and being cooked for—including a glorious eggs benedict breakfast and a Shabbat dinner, finding my way around the combi system, wine tasting at the aspirationally-named “yacht club”, reading, running, learning new boardgames, and, mostly, meeting a lot of fantastic people.

Just outside Gaborone

Botswana is dry. And, because it’s winter, surprisingly cold in the pale mornings. “Just wait ‘til the summer comes,” says every Motswana and long-term expat I’ve met. The sky stretches out blue and blue and blue without even the faintest thought of a cloud, and even the two days so far that have been overcast yielded no moisture. Gaborone is more of a sprawling town than a city, but it’s the largest in the country, so I’ll leave the condescending New Yorker behind for now. The deep pink light of sunset slanting through air thick with dust, the quietly imposing backdrop of Kgale hill rising at the southern edge of the city: these are moments of striking beauty that will stay with me. Botswana is often considered an African “miracle”—a stable, middle-income country with strong government investment in infrastructure, social services and population health. Indeed, I have to say I’ve been impressed.

I’m lucky to be living in a nice apartment provided by the clinic—primarily for American medical residents here to do month-long rotations at the clinic—in a neighborhood surrounded by embassies. So I know I can’t assume my experiences of reliable internet, electricity and running water are at all universal. A quick look at Old Naledi (a high-density, low-income neighborhood that was historically an illegal settlement) and villages just outside of Gaborone, neighborhoods that many of my teenagers call home, certainly makes that obvious.

Nevertheless, I’ve been impressed with the immaculately paved main roads, the relatively easy public transportation, the general quality of building construction, and the potable tap water, and I don’t think my impressions here are too overly biased by my living situation. Even an article critical of Gaborone’s planning, land allocation and development calls the city “extraordinary in African terms… a city lacking in mass poverty, extensive squatter settlements or recurrent civil strife: for all appearances, an orderly, affluent urban area.”

It seems to me that one of the most crucial differences between Accra and Gaborone is population density (about 9,600/km² and 1,500/km², respectively). I notice it in the different textures of daily life, the feel of the city as you walk down the street. Density is more concrete than just noise and bustle: it’s also the traffic that makes everything run late, the restaurants and small-scale businesses that can pop up and slowly grow in unexpected places, and (arguably) greater overlap of rich and poor. And, importantly, it’s the additional wear on infrastructure, including roads, water delivery and electricity grids. Brian Larkin points out that such “material structures produce immaterial forms of urbanism—the senses of excitement, danger, or stimulation that suffuse different spaces in the city and create the experience of what urbanism is.” I can think of numerous similarities between Gaborone and Accra, but ultimately the forms of urbanism in these cities are drastically different.

The simpler explanation for the differing material structures is that Botswana’s GDP per capita is over five times that of Ghana. But I suspect that Gaborone’s public services and infrastructure seem impressive because they endure less wear, and that the cloistering of low-income populations makes it that much easier to extol the prosperity of the rest of the city. These are density-related issues more than financial ones. It will be interesting to see if density rises significantly as the economy further develops and mortality declines (particularly HIV-related mortality), or if the city will rather sprawl.

Jane Jacobs (1961) writes that cities, and creativity and innovation within urban centers, flourish when there is sufficient density for street-level interactions between a diverse array of people. She would certainly prefer Accra to Gaborone, which was designed according to exactly the principles she most opposed. She would also, I think, prefer Old Naledi to Gaborone’s other, more sterile neighborhoods, much as I preferred Kariakoo to Sea Cliff Village in Dar es Salaam.

I imagine a future Gaborone with the same sparsely-populated center and ever more densely-packed neighborhoods around the periphery. Would those densely populated neighborhoods be pockets of collaborative innovation, or would the structural problems of poverty underlying the need for such close quarters staunch such creative vibrancy? A call for better education, health services, and investment in these neighborhoods….

Now that I’ve found my footing, I hope to venture further out of my privileged arena. I’m sure my thoughts on Gaborone’s neighborhoods, infrastructure and urbanism will develop—and probably change completely—as I get to know the city better and from different perspectives.