Fighting the AIDS epidemic in Botswana

AIDS is in the air in Botswana. On the airwaves, actually. They call it the “radio disease,” according to Harvard AIDS Institute Chairman Max Essex, because so many public service announcements urging safe sex are broadcast.

But still the disease rages.

Botswana has the world’s highest incidence of AIDS, infecting 36 to 38 percent of the adult population. Among the population of women most likely to become pregnant, age 25 to 30, it’s even higher, around 50 percent. But the country, among Africa’s most stable and affluent, presents a paradox, Essex said.

Many people attribute the severe African AIDS epidemic to societal factors such as a breakdown of the social structure, government instability, civil war, and poverty. Botswana presents an argument against that thinking, Essex said. Despite a stable government that has persisted peacefully for decades, one of the continent’s highest per capita incomes, and a high government commitment to fighting the disease, AIDS is stealing Botswana’s present and threatening its future.

That the government and people have mobilized against AIDS is obvious in the large cities, Essex said. Public restrooms have piles of free condoms and radio advertisements and billboards educate the public about the disease and promote safe sex.

“It’s not a case where there hasn’t been AIDS education or they’re in denial. It’s a case where it doesn’t work,” Essex said.

Essex recently returned from a seven-month stint in Botswana, to help push along several aspects of the institute’s collaboration with Botswana’s government in the struggle against the epidemic.

During his trip, which lasted from late June to late January, the collaboration unveiled the largest HIV reference laboratory in Africa, set up trials for a vaccine designed to combat the African strain of the AIDS virus, HIV-1C, and provided advice and assistance for a new national treatment program. The program will be the first large-scale treatment program on the continent, aiming to reach 100,000 people living with AIDS.

“That program started Jan. 21 and will be the first large-scale test case of whether drug treatment will work in Africa with AIDS,” he said.

While in Botswana, Essex also did substantial work on the second edition of his book, “AIDS in Africa,” first published in 1994. The volume, a comprehensive reference work, will be published in time for the International AIDS Conference in Barcelona, Spain, planned for July.

Essex’s trip was his longest stay in Botswana, a place he has visited regularly during the five years that the Harvard AIDS Institute has collaborated with the Botswana Ministry of Health. Most of his prior visits have lasted just a week or two.

Part of the reason the work there is so important is that the strain of the disease prevalent there, HIV-1C, is different from that most prevalent in North America and Europe, HIV-1B, on which much of the research attention is focused.

The HIV-1C strain, transmitted through heterosexual sex in Africa, may pose a threat to the rest of the world. Essex said he believes the reason AIDS has spread so rapidly in Africa, compared with the rest of the world, is not because of external factors, such as poverty and instability, but because this strain of the disease is more aggressive and more easily transmitted.

While the HIV-1C virus can be cause for concern in the rest of the world, Essex said he believes the AIDS virus will continue to change over time, as different strains come in contact and mutate. In 50 years, he said, the AIDS virus will look different than it does today.

In the meantime, the AIDS Institute continues efforts to develop both treatment plans and effective vaccines that will work against AIDS in Africa and elsewhere.

Botswana provides a window as to how AIDS can change a society and a view of what’s at stake. Essex said the lives of his African colleagues are often filled with attending funerals of those who’ve died of AIDS.

“Colleagues would have to go to funerals every weekend, often two or three a weekend. Their lives were built around it,” Essex said.

The raging epidemic has caused parents of children — particularly those entering their teen years – to think long and hard about whether to stay in Botswana or move elsewhere.

Essex compared the prevalence of the disease and of AIDS deaths to that of people living in a war zone or near a nuclear power plant during an accident.

“It’s a very, very, very different dimension of the problem than [what] we have here,” he said.