South Africa can learn valuable lessons from neighbouring Botswana where almost 12 000 adults and children access life-prolonging antiretroviral drugs in the public health sector.

Botswana also faces issues of stigma, silence, chronic medical staff shortages, a low knowledge of HIV/AIDS and a lack of experience with ARVs but has gone ahead with providing the drugs in the public health system.

The South African Health Review warns that without substantial investment in the health system, HIV/AIDS may simply exacerbate existing deficiencies.

 The Botswana experience suggests that capacity challenges such as staff shortages, lack of laboratories, storage space and monitoring systems should be addressed simultaneously. Rapid expansion may compromise the quality of an ARV programme, particularly with regards to follow-up and monitoring. Patient enrolment in that country grew exponentially after initial capacity was developed.

The Botswana experience has taught that antiretroviral therapy needs to be implemented by teams – with each site requiring a team of these professionals as well as a full time manager to manage schedules and systems. As is the case at the Médecins Sans Frontières project in Khayelitsha, the antiretroviral project in Gugulethu and others, the Botswana model proves the importance of all patients having a ‘€œbuddy’€ or someone who is aware of the patient’€™s HIV status and who assists with follow-ups, patient tracking and adherence. Rigorous patient follow up in the first three months is also crucial.

Botswana has one of the highest prevalence levels of HIV/AIDS in the world, estimated at 37 percent. The country started its treatment programme in January 2002. Although it has invested heavily in the programme and has a committed leadership, and a relatively smaller number of people needing ARV treatment, the coverage after two years remains relatively small.

By September 15 last year 12 000 patients had enrolled in the programme, 8 000 were on ARVs and 786 had died. If patients enroll on the programme when they are still healthy, the may only begin taking ARVs later on when they are needed.

By February this year, the number enrolled had grown to 19 675 and 11 660 adults and children were on ARVs. Of those patients on antiretroviral therapy, 1 106 had died.

A key challenge facing the provision of treatment in Botswana is that patients often enrol in the treatment programme only when they are very sick and their CD4 counts are low. When this is the case, their chances of recovery are greatly reduced and mortality rates for the ARV programme may be high.

E-mail Anso Thom