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Botswana: Context of the Epidemic

Spring 2001

In the entire world, sub-Saharan Africa is the region most affected by HIV/AIDS. At the end of 2000, 25.3 million adults and children were living with HIV/AIDS in the region, accounting for 70% of the global total. There were 2.4 million AIDS deaths in sub-Saharan Africa during 2000, representing 80% of global AIDS deaths that year. In 2000, 3.8 million people in the region became infected with HIV, representing about 72% of all new global HIV infections. At the end of 2000, the region's adult (15-49) HIV/AIDS prevalence rate was 8.8%. Of the region's HIV positive adults, 55% were women. Over 80% of women worldwide living with HIV/AIDS live in sub-Saharan Africa.

At the end of 1999 (updated data for 2000 [were] not yet available as of December 2000), sub-Saharan Africa accounted for 92% of the cumulative total of the world's AIDS orphans (UNAIDS [Joint United Nations Programme on HIV/AIDS] defines AIDS orphans as children who have lost their mother or both parents to AIDS before the age of 15). During that year, nearly 90% of infants who acquired the virus perinatally or through breast-feeding were African.

The burden of the epidemic is staggering, all the more so given that sub-Saharan Africa contains only about 10% of the world's population. In eight African countries, at least 15% of adults are infected. In these countries, AIDS will claim the lives of about one-third of today's 15-year-olds. South Africa has the highest number of people infected 4.2 million with an adult prevalence rate of 19.9%, up from 12.9% two years ago.

At 35.8%, Botswana has the world's highest adult prevalence rate. Botswana is also experiencing some of the fastest rates of HIV infection in the world.

The following profile was written in October 2000 by Lisa Garbus, a policy editor at HIV InSite. The original article appears at hivinsite.ucsf.edu.



At the end of 1997, Botswana's adult HIV prevalence rate was 25.1%, the second-highest HIV prevalence rate in the world. Approximately 190,000 people were living with HIV/AIDS; of them, 49% were women (UNAIDS 1998).

In October 1999, the government announced that among those ages 15 to 49, the prevalence rate was 29%. It also projected that in 2000, the number of AIDS orphans would reach 65,000 (Agence France-Presse [AFP] 10/15/99). In some areas, the HIV prevalence rate among pregnant women reaches 50% ("African epidemic reaches 'unprecedented' levels." AIDS Alert 1998;13(2) Suppl 4). UNICEF [United Nations Children's Fund] estimated that in 1999, over 30% of pregnant adolescents were infected (Kaiser Daily HIV/AIDS Report 8/16/99).

In June 2000, UNAIDS released figures showing that Botswana's adult HIV prevalence at the end of 1999 was 35.8%, the highest in the world. At that time, 290,000 adults and children were living with HIV/AIDS. Of infected adults, 54% were women. Among females ages 15 to 24, the HIV prevalence rate ranged from 32.55 to 36.07%; for males in the comparable age group, the range was 13.68 to 18.00% (UNAIDS 2000).

According to UNAIDS, between 1988 and 1997, 94% of transmission was heterosexual and 6% vertical [mother-to-child]. The epidemic is fueled by:

  • Insufficient HIV/AIDS knowledge: Despite the educational campaigns mounted by the government, the incidence of infection continues to increase. Interviews with staff at the University of Botswana, for example, found that only about 60% believed that AIDS was very common or that they were personally at moderate to high risk of contracting AIDS. There was also misunderstanding of basic AIDS facts. The study highlighted the need for more aggressive prevention efforts and interventions to address risk factors such as multiple partners, inconsistent condom use, patterns of violence in relationships, and heavy alcohol use (Norr K, Tlou SD, Norr JL, et al. "AIDS prevention beliefs and practices among urban workers in Botswana: implications for prevention." Int Conf AIDS 1998;12:1164 [abstract no. 60896]). Language used in discussing HIV/AIDS and STIs [sexually transmitted infections] can also impede prevention efforts; see, for example, Chipfakacha VG. "Inappropriate language as a barrier to health education: its possible impact on STD[sexually transmitted disease]/HIV/AIDS information, education and communication (IEC)." Int Conf AIDS 1998;12:958 [abstract no. 43569]).

  • Fatalism and stigma associated with HIV/AIDS.

  • Status of women, particularly their lack of power in negotiating sexual relationships

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  • Cultural practices such as polygamy.

  • Constraints to good sexual and reproductive health: According to Botswana's Third Family Health Survey, published in 1996, almost 60% of first-time pregnancies are to women ages 15 to 19. IPPF [International Planned Parenthood Federation] notes that family planning services are constrained by a shortage of trained health personnel. STI prevalence is thought to be high.

  • Sexual abuse: An April 2000 survey conducted by the government's Women's Affairs Unit indicates that 67% of secondary school students -- mainly girls -- have been sexually harassed by their teachers. One-quarter of students reported being subjected to such harassment on a regular basis. Twenty percent stated they had been asked by teachers to have sex with them; of these girls, 42% complied, primarily because of fear of lower grades if they refused. This phenomenon prompted 11% of respondents to consider leaving school, and the proportion of secondary school students who are female has been declining. Currently, there is no sexual harassment policy nor are there procedures for filing complaints within schools themselves, although discussions are under way to formulate them (The Reporter [Gaborone] 4/10/00).

  • Decreasing economic growth: The mining industry, particularly diamonds, accounts for about 33% of the country's GDP. The country's economic growth rate -- averaging 7.3% between 1970 and 1995 -- has been the highest in the developing world (World Bank country brief on Botswana). Growth has slowed, however, from 8% in 1997/98 to 4.5% in 1998/99. This decrease is mainly attributed to a 4.4% decline in mining output because of decreased demand for diamonds and a 3.1% decline in agriculture due to drought. The government is seeking to diversify the economy and has seen growth in the tourism, financial, and manufacturing sectors. Currently, however, it is contending with an unemployment rate of 19% and increasing poverty; data for 1997 indicate that 38% of households lived below the poverty line (AFP 11/16/99 and 2/7/00).

  • Migration: Botswana both exports and imports labor; there is much mobility among the mines in southern Africa. There is also a great deal of intracountry migration.


World Health, Education, and Population

Indicator

Botswana

Sub-Saharan Africa

Less-
developed countries

More-
developed countries

World

Adult HIV/AIDS prevalence rate 1999 (%)

35.80

8.57

n/a

n/a

1.07

GNP per capita 1998 (US$)

3,070

520

1,260

19,480

4,890

Health expenditures (public) per capita 1997 (US$)

52

n/a

n/a

n/a

n/a

Population mid-2000 (millions)

1.6

627.0

4,883.0

1,184.0

6,067.0

Population growth rate 2000 (%)

1.55

2.50

1.70

0.10

1.40

Population doubling time at current growth rate (years)

45

27

42

809

51

Projected population 2025 (millions)

1.2

1,006.7

6,575.0

1,236.0

7,810.0

Percent of population < age 15 (2000)

41

45

34

19

31

Percent urban 2000

49

25

38

75

45

Maternal mortality ratio 1999

250

870

350

14

295

Total fertility rate [TFR] 2000

4.1

5.8

3.2

1.5

2.9

Infant mortality rate [IMR] 2000

57.2

94.0

63.0

8.0

57.0

Life expectancy at birth 2000 (years)

44

49

64

75

66

Adult male literacy rate 1995

70

65

79

n/a

81

Adult female literacy rate 1995

75

47

61

n/a

65

Gross male primary school enrollment ratio 1990-96

111

82

105

104

104

Gross female primary school enrollment ratio 1990-96

112

67

92

103

94

Percent of population with access to safe water 1990-98

90

50

72

n/a

72

Notes: n/a = not available. More-developed regions/countries = Europe, North America, Australia, Japan, and New Zealand. All other regions and countries = less-developed. Maternal mortality ratio (MMR) per 100,000 live births. TFR = average number of children per woman. IMR per 1,000 live births.

Sources: All indicators from Population Reference Bureau 2000 World Population Data Sheet except HIV/AIDS prevalence rates from UNAIDS Report on the Global HIV/AIDS Epidemic June 2000; country MMRs from UNFPA The State of the World Population 1999; regional MMRs and health expenditure data from World Bank HNP Sector Strategy 1997; and literacy, primary enrollment, and access to safe water from UNICEF 2000 State of the World's Children.


Socioeconomic Impact

  • Life expectancy: According to the U.S. Census Bureau, in the absence of AIDS, life expectancy in Botswana would now be 62 years. In 2010, life expectancy is projected to be 39 years; in the absence of AIDS, it would have risen to 66 (U.S. Bureau of the Census 1999).

  • Human development: Because of HIV/AIDS, Botswana fell 26 places on the Human Development Index [HDI] between 1996 and 1997. It currently ranks 122nd out of 174 countries. [Ed. note: the HDI measures a country's achievement in terms of life expectancy, educational attainment, and adjusted real income.]

  • Household impacts: In a report released in May 2000, the Botswana Institute of Development Policy Analysis projected that in the coming decade at least 50% of households will have at least one member infected with HIV and that one-quarter of households will lose at least one income earner. At least 2% of households will lose all breadwinners (Panafrican News Service 5/3/00). The report also stated that the number of households living in poverty will rapidly increase because of AIDS, and it projects that per capita income for the poorest households will decrease by 13% (AFP 5/15/00).

A September 1999 report by the POLICY Project of the Futures Group entitled The Economic Impact of AIDS in Botswana cites 1992 data that indicate that 95% of orphans in Botswana -- including AIDS orphans -- were cared for by extended family members; this coping mechanism will be strained, however, given the increased number of AIDS orphans. As most AIDS deaths occur in the working-age population, households will lose breadwinners, and poor households are projected to experience increased impoverishment. About one-half of Botswana's households are headed by females, rendering them particularly vulnerable to the impact of AIDS-related illnesses and deaths.

  • National productivity: A study by the Botswana Task Force on AIDS projects that the direct and indirect costs associated with HIV/AIDS (e.g., medical costs, lost productivity) will have increased sevenfold between 1996 and 2004, accounting for 4.9% of the country's wage bill. The above-mentioned report of the Botswana Institute for Development Policy Analysis projected that AIDS will reduce the GDP growth rate by 1.5%. Given high death rates, however, per capita GDP is not expected to be affected.

    According to the institute's report, within 25 years the country's economy will be 31% smaller than it would have been in the absence of AIDS. The institute projected that over the next decade HIV/AIDS will result in a cumulative budget deficit of 2% annually; reduce government revenue by 7%; and cause expenditures to rise by 15%. Because of the epidemic, poverty alleviation expenditures will increase as the government compensates households living below the poverty line for the loss of breadwinners. The institute also examined how AIDS is exacerbating the country's labor shortage, with the acute shortage of skilled labor expected to result in a 12 to 17% rise in wages.

    The POLICY Project report previously cited examined five firms in Botswana and found that HIV/AIDS had the greatest impact on the transport sector and the least impact on the financial sector. Sick leave and medical care accounted for the largest share of direct AIDS costs that these firms were incurring.

    Many companies are taking out "key man" insurance to cover the costs of recruiting replacements for people in critical positions if they die. Premiums on some group life insurance policies have already doubled, although the country is still at a relatively early stage of the epidemic, with the vast majority of young adult deaths to come (UNAIDS 1999).

  • Health sector: The report of the Botswana Institute for Development Policy Analysis cited above projected that health expenditures will increase dramatically. If Botswana emulates other countries and spends between one and four times per capita GDP on each HIV/AIDS case, then total recurrent health spending will rise by 5 to 19%.

    The POLICY Project report found that in Botswana, approximately 60% of hospital beds are occupied by people with HIV/AIDS. In each of the country's two largest hospitals -- Gaborone's Princess Marina and Francistown's Nyangabwe hospitals -- 70% of beds are occupied by AIDS patients (AFP 10/15/99). This scenario has prompted the government to allocate US$6 million to strengthen home-based care programs (see "Current Response," below).

    Between 1989 and 1996, the TB [tuberculosis] case rate increased by 120%, primarily because of HIV/AIDS (Kenyon TA, Mwasekaga MJ, Huebner R, et al. "Low levels of drug resistance amidst rapidly increasing tuberculosis and human immunodeficiency virus co-epidemics in Botswana." Int J Tuberc Lung Dis 1999;3(1):4-11). In 1997, there were over 7,200 TB cases and 600 reported deaths, although the actual figures may be much higher. Botswana, however, has among the lowest levels of resistance to TB drugs in the world; moreover, there is good integration of TB into primary health care (Africa News Service 5/27/99).

    The U.S. Census Bureau projects that by 2010, infant mortality will be 55 deaths per 1,000 live births; in the absence of AIDS, the rate would have been 26. Under-five mortality is projected to be 120 deaths per 1,000 live births, whereas it would have been 38 in the absence of AIDS.

  • Education sector: The POLICY Project report cites a Botswana government evaluation of the impact of AIDS on the education system, which found that both the demand for and supply of schooling will be affected. Demand will be affected as fewer children attend -- because of the need for labor at home -- as well as financial pressures that reduce resources for uniforms and school supplies. The supply of schooling will decrease due to the death of teachers -- who are already in short supply; each year, Botswana loses 2-5% of its teachers to AIDS.


Current Response

  • A national AIDS policy was launched in 1993. The president chairs the National AIDS Council, the government's highest national advisory body on the epidemic, which is housed in the ministry of health.

  • In October 2000, President Mogae launched the AIDS Coordinating Agency (NACA), a multisectoral body charged with monitoring, evaluating, facilitating, and coordinating the national response to HIV/AIDS. NACA will also serve as the secretariat of the National AIDS Council. In October 2000, President Mogae also announced an intensified information, education, and communication campaign against HIV/AIDS. The campaign will target all sectors of society, including sex workers, mobile workers, and schools. HIV/AIDS will form part of the syllabus from primary to university level, and IEC campaigns will also target out-of-school youth. House-to-house sensitization will also be undertaken (Botswana: National HIV/AIDS Co-ordinating Agency, Wene Owinom, Panafrican News Agency, October 29, 2000).

  • President Mogae mentions HIV/AIDS in every speech and has called HIV/AIDS "a threat to [the nation's] continued existence." Ministry officials discuss HIV/AIDS at each Khotla (tribal) meeting. Eighty-five percent of expenditures to combat HIV have come from the Government of Botswana (Simukoko C. "Social impact and response of the community." Int Conf AIDS 1998;12:717 [abstract no. 34154]). By 2014, the number of children orphaned by HIV/AIDS in Botswana is expected to reach 214,000 from 65,000 at the end of 1999.

  • In 1998, the government launched a program to provide those infected with HIV a monthly allowance of 90 pula (about US$20). The ministry of health has allocated 16.5 million pula (about US$3.6 million) for AZT [Retrovir] and breast milk substitute purchases for HIV-infected pregnant women (Kaiser Daily HIV/AIDS Report 10/2/98).

  • In 1996, the government allocated 30 million pula (about US$6.6 million) for a community network to provide home-based care for AIDS patients and to ease the pressure on hospitals. This represents an annual savings within the health care budget of approximately US$600,000 (figures cited in the POLICY Project report). Traditional healers also play an important role in AIDS care (see, for example, Chipfakacha VG. "STD/HIV/AIDS knowledge, beliefs and practices of traditional healers in Botswana." AIDS Care 1997;9(4): 417-25).

  • In 1997, the government formulated policies to address children in difficult situations, including AIDS orphans (Mbonini KF, Motlhabani PM. "AIDS orphans: a shared responsibility: Botswana experience." Int Conf AIDS 1998;12:480 [abstract no. 24202]). NGOs [nongovernmental organizations] and CBOs [community-based organizations] are also carrying out projects to try to meet the needs of AIDS orphans.

  • The POLICY Project report cites a 1997 AIDSCAP study of two firms in Botswana that found that their HIV prevention programs cost only a fraction of the annual cost of AIDS they incurred.

  • In February 2000, Botswana opened its first HIV reference laboratory, funded with a $4.9 million [U.S.] grant from Bristol-Myers Squibb, along with funds from the Government of Botswana and Harvard University. The lab will conduct 100 to 200 HIV tests a day and will investigate the 1C subtype of HIV, which is responsible for half of the world's HIV infections, particularly in Africa and India.

  • In March 2000, the Bristol-Myers Squibb Foundation awarded grants to two community-based HIV/AIDS programs in Botswana, as part of its Secure the Future program. The Botswana Christian AIDS Intervention Program will receive a five-year grant of $400,000 [U.S.] to fund HIV/AIDS counseling, home visits, and other services. The Reetsanang Association of Community Drama Groups will receive a one-year award of $32,000 [U.S.] to fund theater-based HIV awareness efforts.

  • In 2000, Botswana opened a LifeLine center, offering free, anonymous counseling services. Other southern Africa LifeLine centers have found that most calls they receive are from those with HIV/AIDS or those seeking pretest counseling. Some LifeLine centers in other countries have also trained counselors for companies [that] have established in-house AIDS awareness programs. The Botswana center is still awaiting the installation of telephone lines, but is offering face-to-face counseling (The Reporter [Gaborone] 4/20/00).

  • The mining conglomerate Debswana has stated that candidates for scholarships and apprenticeship training programs will have to undergo an HIV test; applicants found to be HIV-positive will be rejected. The company based its decision on return on investment. One response to the decision was to encourage the company to offer counseling to those candidates found to be infected with HIV (The Reporter [Gaborone] 4/10/00).

  • Cleric Criticizes Church's Position on HIV/AIDS, Panafrican News Service, 5/10/00.

  • Miss Universe [1999], Mpule Kwelagobe, from Botswana, has used her title to raise awareness of HIV/AIDS, both at home and abroad.

  • Myriad bilateral and multilateral organizations, NGOs, and CBOs are working on HIV/AIDS.

Lisa Garbus is a policy editor at HIV InSite.


Back to the SFAF BETA Spring 2001 contents page.



  
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This article was provided by San Francisco AIDS Foundation. It is a part of the publication Bulletin of Experimental Treatments for AIDS. Visit San Francisco AIDS Foundation's Web site to find out more about their activities, publications and services.
 
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