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Reluctance to face tests slows Botswana AIDS fight

TUTUME, Botswana -- The prevailing wisdom on fighting AIDS in Africa has been that if the money was available and countries built a solid treatment program offering free drugs, people would come in droves.

That wisdom has proved wrong in Botswana. It offered free antiretroviral drugs. It has put up $30 million annually for AIDS programs. It attracted loads of outside help -- the Bill & Melinda Gates Foundation and the drug giant Merck & Co. each contributed $50 million over five years, and the Harvard AIDS Institute has sent teams of experts and built advanced AIDS laboratories. The country also trained hundreds of doctors and nurses to control the pandemic and will have opened a remarkable 16 AIDS treatment clinics by the end of this year.

Yet, Botswana is barely making a dent.

Fewer than 9,000 people are taking the life-extending antiretroviral medicines. Less than 8 percent of the population knows whether it has the virus -- dangerous in a country where more than 1 in 3 adults are believed to be infected, the highest national rate in the world. The lessons of Botswana's AIDS program will be studied in Washington on Wednesday at a forum cochaired by Senate majority leader Bill Frist of Tennessee. President Festus Mogae of Botswana will give the keynote address.

Here, outside the one-story Tutume Primary Hospital, the promise and the problems of Botswana's fight were in full view during a recent visit.

Walking through an outdoor waiting room, Dr. Alexander Yugu George asked several patients whether they had been tested for HIV, the virus that causes AIDS.

Margret Ndawana, 21, said she was waiting for the results. "I wanted to know my HIV status," she said.

The doctor beamed. "If you know your status, you can protect yourself," he said. "If you don't, it's very difficult for us to treat you because you'll probably come in very late."

Lying next to Ndawana was Johnson Akuge, 54, who was motionless and bone thin, and surely came in too late. He seemed the embodiment of the state of AIDS in Africa today: He never got tested for HIV, his relatives said, and the virus ran roughshod through him, said the doctor.

From Washington to Geneva to Johannesburg, the public debate over saving people like Akuge has been dominated by three issues: whether rich countries would dramatically increase funding to fight AIDS globally; whether prices for antiretroviral drugs could be slashed, opening the possibility for widescale treatment; and whether African countries could rebuild health systems so millions of poor people could receive the treatments.

The crux of the problem in Botswana, say health officials in the country, is that most people, for whatever reason, have been reluctant to find out whether they are infected. US-funded voluntary counseling and testing centers have given 84,000 HIV tests to Batswana, as the people are known, in the past three years. If that rate continues, said Joseph Huggins, the US ambassador to Botswana, "it would take 20 years to test the entire population. Botswana doesn't have 20 years. We need to do something."

That crucial push may come from a new initiative championed by health specialists in Botswana and the US Centers for Disease Control and Prevention but never tried in Africa: giving HIV tests as a routine part of medical checkups in public and private clinics.

The Tutume hospital, in a rural community in northeast Botswana, near the Zimbabwe border, is the first site in Africa to routinely screen patients for the virus. Dr. George said it is working well.

"I haven't had one patient refuse the test," he said, "and I've seen over 200 patients."

Botswana is believed to have 350,000 people infected out of a population of 1.6 million, or 22 percent of the country, including young children and the elderly. The overall infection rate for Botswana's adult population is believed to be more than 35 percent.

"Our single largest problem is the lack of knowledge of HIV status," said Ernest Darkoh, who earned his medical degree at Harvard and a business degree at Oxford and now works in the Ministry of Health overseeing the country's treatment program. "When you have that many people who don't know their status, anything could happen. If each person infected another person, then you could have 35 percent prevalence turn into 70 percent prevalence. It's insane."

Darkoh and other health officials in Botswana say they believe routine testing is the best opportunity to improve the treatment program rapidly; decrease the burdens on hospitals by treating people with HIV or AIDS at earlier stages, not just those near death; and give them a new prevention tool.

Mogae, who announced two weeks ago that the government would begin routine HIV testing, said in a recent interview that he does not want health workers asking people for their consent to do the screenings; he wants the burden to be on patients to object. The policy remains in flux.

"I'm very frustrated," the president said in his office. "We think because of the stigma attached to this sexually transmitted virus, and because some of our religious people have said this is a curse or those who have it are sinners, that people are afraid to get tested. One way of removing the stigma is making testing of HIV a routine thing."

Already, a handful of local human rights lawyers has objected to any tests that don't give patients an easy way to decline. Some rights groups also believe Botswana's policy could have the unintended impact of stopping people from seeking treatment in clinics or hospitals for other illnesses.

Willem A. Landman, executive director of the Ethics Institute of South Africa, who for seven years was a medical ethicist at East Carolina University in Greenville, N.C., said those arguments ignore the reality that Botswana is in the midst of a public health emergency.

"You have to make sure everybody knows what you're going to do at the point of service," Landman said. "But I would not go through a rigorous informed-consent process that you see in the States. . . . Botswana's future is at stake. If only 20 percent of what was happening in Botswana was happening in the United States, they would have compulsory testing, not routine testing."

In Botswana, the visual reminders of AIDS are everywhere. Billboards show pictures of a soccer ball covered with a condom. Funeral parlors advertise 24-hour service. Emaciated people linger in downtown Gaborone, the capital.

The ubiquitousness of AIDS may have a mixed effect, though. The increasing numbers of young and middle-aged people dying, say some observers, could shock Batswana into getting tested. But it also could reinforce a false message of no hope, even with antiretroviral drugs.

"The death rates actually have a negative impact, giving a sense that nothing can be done," Merck's chief executive, Raymond V. Gilmartin, said in a telephone interview from the company's headquarters in New Jersey. "The numbers of people being treated is a significant factor in whether people get diagnosed. As that experience builds, the people getting tested will follow, and maybe this will accelerate."

The decision to take an HIV test is highly personal, of course, dependent on such factors as the support of friends and family, education levels, fear, anger, and guilt.

"Why aren't more people testing here? The real answer is `I don't know,' " said Tsetsele Fantan, who until last week was the Debswana Diamond Co.'s director of HIV/AIDS impact management.

This month, Fantan will become director of the African Comprehensive HIV/AIDS Partnerships, which is backed by the government, the Gates Foundation, and Merck.

The results of Debswana's aggressive treatment program disappointed her, Fantan said: After two years, just 19 percent of those infected with HIV or AIDS registered with the company program, which offers free treatment for workers and their spouses.

She says that some people aren't getting tested because they feel well and won't seek help until they become very ill.

"How many people go see a doctor for a health checkup when they are not sick? Very few," Fantan said. "Ordinary people in Botswana don't go to a doctor and say, `Doc, I feel fine, but tell me what is wrong with me?' "

John Donnelly can be reached at donnelly@globe.com.


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