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.