- Despite a rare discovery of a pill that could prevent new HIV infections,
Gov’t is reluctant to despatch it to the public
- Gov’t fears that the pill may lead to a more reckless behaviour
While most SADC member states have embraced a newly discovered pill globally found to have unprecedented reduction in new HIV cases and swiftly adopted it, Botswana – which is heavily burdened by the disease – faces a series of barriers which may affect implementation and roll-out of the pill.
The pill can be taken by anybody who is HIV negative before exposure to the virus to prevent infection. However, as things stand in Botswana, the pill will only be availed to a selected few who are deemed most at risk.
This is despite other countries moving far ahead and casting the net a bit wider. Experts say Botswana’s reluctant slow pace may soon come back to haunt the country as it will be forced to pay the costs of new national infections which could have long been dealt with.
At the top of the troubles facing Botswana in relation to the pill that is currently making headlines around the world are guidelines and recommendations prioritising the most at risk populations, sex workers and homosexuals, who are outlawed and ‘outcultured’ in Botswana.
The government is in the process of appealing a court ruling that legitimised homosexuality. Sources say the implementation and rollout to the outlawed and undesirable groups will not be easy as in other countries.
Third on the controversial priority list is sexually active youthful women aged 15 to 24 whom the government and stakeholders are also having a headache over regarding where to target in that category.
A public health specialist with the Ministry of Health and Wellness, Dr Bonaparte Nkomo, has told this publication that stigma may stand in the way of this category as many HIV negative young girls may not want to be associated with ARVs. The pill will be available for these groups on a voluntary basis.
The PrEP ambassador for Botswana, Beauty Tlhalerwa, says “Botswana’s biggest challenge with PrEP is politics and fossilised laws”. She warns that Botswana is likely to miss out on the opportunity as the world progresses. “Our laws and policies should be rights and needs-based,” Tlhalerwa says.
In an interview with this publication, Tlhalerwa said there were also reservations and fears that compared to other nations, Batswana are promiscuous compared and may abandon other prevention methods like condoms as a result, further risking attracting other deadly sexually transmitted diseases.
In 2017, some countries – notably Kenya and South Africa but also eSwatini – started serious PrEP availability programmes for wider populations. In South Africa, roughly 30,000 people have started taking PrEP, Kenya has initiated PrEP in about 25,000 people, Zimbabwe in about 5000, while reliable information is that the 2250 in eSwatini who have been assessed for PrEP will, if all of them start it, be about three times the number per head of population compared with the much larger Kenya.
Lesotho and Zambia have also started programmes. In South Africa, PrEP was first introduced into sites for female sex workers (FSWs) in June 2016, then into sites for MSM (Men who have Sex with Men) in April 2017, into university sites for young students in October 2017, and most recently in May 2018 into general sites for young people. The Third Botswana National Strategic Framework for HIV and AIDS 2019 to 2023 report indicates that Botswana has the third highest HIV prevalence in the world, following eSwatini and Lesotho in 2016.
Despite being included in the 2016 guidelines, the Ministry of Health and Wellness is still hesitant and piloting the project when countries are at implementation stage. Adding PrEP to combination prevention services is affordable, despite the costs associated with its rollout since those costs are expected to be offset by the savings made from avoiding new HIV infections and the associated benefits of increased contact with sexual health services by people at high risk of HIV infection.
Botswana spends handsomely to provide ARVs to its over 300 000 HIV positive citizens. Public health specialist Dr Nkomo has admitted that Botswana is lagging behind compared to other countries but says “we will get there with time”. According to him, it is anticipated that the pill will reduce the ARV burden on the government and avert new infections but says the guidelines are that only the key populations and adolescent girls aged 15 to 24 should be assisted on a voluntary basis.
Dr Nkomo has confirmed that “there are worries about Batswana’s sexual behavioural patterns which will need to be addressed heading into this direction as condoms may be a thing of the past”. Asked about politics and hostile laws versus implementation, Nkomo expressed the hope that the government would not pursue its appeal against the homosexuals judgement, saying “we are in the treat-all and zero infections era”.
The protection levels of PrEP are usually reached after between four and seven daily doses. The National Aids and Health Promotion has issued a list of those who are supposed to take the pill and included those who are HIV negative and have HIV positive partners, those are HIV negative and do not always use a condom, those who are negative and trade sex, those who are negative and have multiple partners, those who are negative and have promiscuous partners, those involved in same sex relationships and those who are involved in the use of drugs.
A source in the ministry has confided to this publication that there is strong demand and need for PrEP from many people at high risk of HIV infection and that by the time Botswana wakes up to include all, there will be hundreds of other new infections to deal with. The source says as things stand, people may seek to obtain PrEP through unofficial channels. “But there are other challenges of self-prescribing which result in inadequate or no follow-up with no linkage to health service support, as well as increased risks of using substandard products, drug resistance and reduced impact,” the source warmed.
The government recently took a decision to increase and redirect funds towards HIV/AIDS programmes as the country is struggling to retain and attract donors due to its middle income status. The pill presents an opportunity for the country to escape from these challenges. Despite this, some already dismiss the sustainability of the programme in Botswana, saying government facilities have failed to provide condoms as the most used or preferred method of prevention.
The pill is currently only accessible from health facilities at Bontleng (Gaborone), Tlokweng, Francistown, Thamaga Primary Hospital and Scottish Livingstone Hospital in Molepolole. Other stakeholders, however, complain that the government is advertising the pill as if it was now available for everybody.
PrEP experiences in other countries
High drop-out rates in many programmes were reported, especially among female sex workers but also among young women and men in general. In many studies, a majority of those who had initiated PrEP did not return after their first visit. But the most frequent reason given for not continuing with PrEP was the experience of side-effects during the first month.
Two studies from South Africa and Kenya had similar-enough results to suggest that acute side-effects such as nausea, abdominal pain, headache and dizziness might be more common or more severe than has been reported from MSM in high-income countries and need to be taken seriously.