Botswana adopts
radical new approach to HIV testing

When Botswana first offered free AIDS treatment, health authorities in one of the world's most infected countries braced for a rush. It didn't come. Most people were still too afraid to get tested for the deadly scourge. The startling reluctance to seek help in one of the few African nations able to provide it prompted a radical rethinking of how testing is done here. An HIV test is now offered as a routine part of any medical visit. In most countries, patients are left to ask for a test themselves, then put through extensive counseling to prepare them for the outcome. But despite decades of education campaigns, World Health Organization officials estimate that fewer than 10% of HIV-infected people in the African countries at the epicenter of the pandemic realize they have the virus that causes AIDS. Botswana's decision to start routine testing initially caused alarm among international health advocates, who worried that patients' rights to confidentiality and informed consent would be compromised. "I think the first right of a human being is to be alive. All other rights are secondary," countered Segolame Ramotlhwa, operations manager for the national treatment program dubbed Masa, or New Dawn. He argued that confidentiality was being confused with secrecy, making doctors reluctant to even suggest testing for a disease that has infected more than a third of Botswana adults. Doctors believe pulling patients aside for special counseling is intimidating and helps fuel the stigma that keeps patients from seeking help. Howard Moffat, medical superintendent at Princess Marina Hospital in the capital, Gaborone, said people who were not sure they wanted to know their HIV status often emerged from counseling determined not to be tested. "I think the medical profession itself...played a major role in creating this fear of AIDS and this quite irrational reluctance to be tested," he said. Since the beginning of 2004, Botswana has treated HIV tests like any other medical procedure. Patients have the option to refuse, but doctors say most don't. They estimate up to 35% of the 1.7 million population now know their status. If the test result is HIV-negative, a health worker will briefly reinforce the importance of staying that way. If HIV-positive, the patient will receive help to manage the condition and treatment when needed. Most people only see a doctor when their symptoms are severe, by which time it may be too late. It takes three to four times more resources to save someone who arrives on a stretcher than someone who is still on their feet, Ramotlhwa said. When Kelatlhilwe Segole was pregnant, she was not offered an HIV test and unwittingly passed the virus to her daughter, now a 7-year-old. Both are now on treatment, but her husband refused to be tested until he was in a wheelchair. "I kept telling him he will die because of not knowing his status," said the fragile-looking 27-year-old, as she waited in a daylong line for her medicine. Much of the emphasis on voluntary testing and counseling came from HIV's early association in the United States with homosexuality, which is widely taboo in sub-Saharan Africa, home to more than 60% of the estimated 40 million infected globally. This became the international standard, even though HIV is now overwhelmingly a heterosexual disease that killed 2.4 million on this continent last year alone. Life-prolonging antiretroviral medicines that have turned HIV into a manageable chronic condition in wealthier countries remain out of reach for all but a handful in Africa. They are expensive, and most countries lack the medical staff and infrastructure to dispense them widely. Botswana was the first country to offer free medicines to all who need them in 2002. It now has half the estimated 110,000 in immediate need on treatment. Botswana rights activists agree on the urgency of reaching the other half but worry that many consent to a test without being prepared. There is a cultural reluctance to question doctors here. A study of antenatal clinics in Botswana's second city, Francistown, found that 90.5% of women tested for HIV in the first three months of the new policy, compared with just over 75% in the last four months of the voluntary approach. Many, however, failed to return for their results. "At the moment it seems like a numbers game, a total drive to get people to know their status. The question is, Then what?" said Christine Stegling, of the Botswana Network on Ethics, Law, and HIV/AIDS. "I have a feeling that what is happening is, health care providers are getting out of communicating meaningfully with their patients." The new approach is more likely to reach women, who are more frequent visitors to health services because of pregnancies. Men continue to be underrepresented in Botswana's treatment program. Stegling believes testing numbers are going up in part because people are starting to see the effects of treatment. WHO and UNAIDS now encourage routine testing in all HIV-prevalent areas where antiretrovirals are available. But for millions, a positive result remains a death sentence. (AP)