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A battle line in Botswana AIDS fight

By John Donnelly, Globe Staff | October 24, 2003

GABORONE, Botswana -- In June, President Festus Mogae fell ill and began to grow thinner. He feared the worst: that he had AIDS.

"I thought about it, losing all this weight. I concluded that I must have the virus," he said in an interview yesterday in his office. "I was psychologically prepared."

He was screened but tested negative, the 64-year-old president said. "I was relieved, yes." The diagnosis was stress-related diabetes.

Mogae's frank comments -- no other African leader has admitted fears of having AIDS -- set him apart from most presidents in sub-Saharan Africa, where more than 30 million people are estimated to be infected with HIV or AIDS. Likewise, his AIDS-fighting policies remain several steps ahead of the other leaders.

That is partially due to the depth of the problem here. An estimated 35 percent of Botswanans between the ages of 15 and 49 are infected with HIV, giving the country the highest national rate in the world last year.

Last week, Mogae told the nation in a televised address that hospitals and clinics would begin routine AIDS tests for everyone seeking treatment for any malady, although a patient could refuse to have the test done. It would be a first in Africa. In the United States, health workers often order HIV tests if a person is suspected of having the virus.

But in an interview yesterday, Mogae went further than he did in his earlier comments, saying doctors and nurses should go ahead and test patients unless they are specifically asked not to. He said the health workers should not ask whether the patient wants to be screened.

In some cases, Mogae said, doctors or nurses could refuse to treat patients if they refuse to be tested for HIV.

"If the health provider does suspect the person is HIV positive, and if the person refuses to be tested, it seems to me that the health provider is free to say, `I am unable to help you.' You have certain principles that you have to follow," he said.

Asked whether health workers need to counsel patients before administering the test, as is currently done in other developing countries, Mogae said: "I don't think they should. . . . If you are going to a health clinic, now you are going to be tested."

His stances are likely to raise concerns from human rights advocates, who have been sensitive to any infringement on the right of patients to refuse medical care, including HIV testing.

The advocates also have fought for all results to remain confidential. Under Botswana's new program, health workers will record names of patients when they take blood samples.

Paul S. Zeitz, executive director of the Global AIDS Alliance, complimented Botswana's plan for routine testing in hospitals, but said Mogae's statements on withholding treatment were "draconian."

Earlier this year, Botswana's National AIDS Council recommended routine testing because of the lower-than-expected number of people seeking free antiretroviral drug treatment. Even though 100,000 people in Botswana are now estimated to need the life-extending drugs, just 13,000 have registered for the programs and about 9,000 are taking the medicines.

Coordinators of the program -- which is being run by the Health Ministry, the Harvard AIDS Institute, the Bill & Melinda Gates Foundation, and Merck Co., the giant drug company -- have determined that the greatest impediment for rapidly expanding treatment is that people do not know whether they are infected with HIV. Too few people are coming in for testing.

"A lot of people are dying recently who have no business to die. The government is going out of its way. . . . It's their fault if they don't get tested," Mogae said.

"Those who are negative would have added incentive to stay negative. Those who are already positive will have help available for free. They do not need to die now," he said.

Asked whether his family has sought testing, Mogae said he had encouraged them to do so but did not know whether they followed his advice.

Asked whether a relative or close friend had died of AIDS, he said no. "Only acquaintances," he said.

Last month, South African President Thabo Mbeki was asked the same question. He said no, touching off many comments of disbelief, because the HIV prevalence rate among adults in his country is about 25 percent.

On a separate issue, Mogae declined to comment on the status of quiet regional diplomatic efforts for new elections in neighboring Zimbabwe that would lead to the end of President Robert Mugabe's rule. "Nothing we can say will help," he said.

But Mogae said the huge influx of Zimbabweans into Botswana has put a severe stress on his country.

He said Botswana is repatriating about 2,500 Zimbabwean refugees every month.

"We don't have the capacity to handle any more of them," he said. "It is also having an adverse impact on the culture of our people. Our people are very friendly, but this is breeding xenophobia here, and antisocial, unfriendly attitudes."

John Donnelly can be reached at donnelly@globe.com