By Mpho Mogodi On my first weekend at one of the main government referral hospitals in my home country of Botswana, I was tasked with certifying the deaths of nine adults. All had died from AIDS. One was a grandmother. Her name was Lorato. In the previous three years, she had buried her three children who had died of AIDS. Now she was dead. The pediatric ward was even more heartbreaking. There I met Neo, a 9-month-old girl who was admitted for the fifth time in six months. She suffered repeated childhood illnesses. This time Neo did not leave the hospital alive. That was my initiation into clinical practice in Botswana more than 10 years ago. At the time, most people declined to have an HIV test following voluntary counseling and testing (VCT) because they feared a positive test would mean a death sentence. They also feared being stigmatized by health providers and their family members. At the time there was no treatment for AIDS in Botswana. Today, the Loratos and Neos at least have hope. In the past decade, Botswana has made significant strides against HIV/AIDS, but more still needs to be done. In 1999, Botswana became the first country in Africa to initiate a prevention of mother-to-child transmission (PMTCT) program. In 2001 it was scaled up to be nationwide. The following year, Botswana took the lead to become the first African country to offer free antiretroviral therapy to her citizens. Today, more than 80 percent of citizens eligible for ARV therapy are receiving treatment. Routine opt-out and dry-blood-spot HIV-testing have enabled more adults and children to be tested for HIV expeditiously. HIV incidence and infection rates have fallen in recent years, although I cannot call it a success because there are still so many new infections every year. What more needs to be done? The United States has long played a leading role in the HIV/AIDS response in Africa and in many ways has supported the Botswana government in its scaled-up response to the epidemic. But the biggest questions remain: How do we build local capacity and leadership to respond to the epidemic in a long-term, sustainable way? What will happen when bilateral and multilateral partners and funding programs like the President’s Emergency Plan for AIDS Relief (PEPFAR) ends? What can be done about the huge lack of human resource capacity in every area of the HIV response? This is the right time to think about these issues. How will small countries like Botswana (which does not have a medical school) and Malawi (which has high emigration rates of its health care providers) cope with the epidemic? How can the HIV treatment programs expand without an adequate and capable health work force? As U.S. and international agencies and organizations partner with Botswana in this huge task, they should support true capacity building. With proper training, we in Botswana can sustain and even expand interventions. It is important to involve local people as equals in the design and development of interventions to encourage ownership, capacity building and sustainability. Multilateral organizations should listen to the people of Botswana (and other countries) to learn about national priorities regarding combating HIV/AIDS. This will also help to build the entire health system infrastructure and not just single disease programs that occasionally disrupt the national health system equilibrium. The U.S. government and its implementing agencies have provided funding and leadership for the scale-up of the HIV/AIDS treatment response. It is time also to provide the same leadership for long-term capacity building and coordinated response. All this will encourage respect for the local culture and contextualize interventions targeted to the countries as well as address possible discriminatory human resource policies against qualified locals. Building health care system infrastructure, coordinating HIV/AIDS programs and training local people are the best hope for Africa, and for Botswana in particular. The time is now. If not now, when? Mpho Mogodi is a physician from Botswana. Currently, she is an MPH student and De Beers Scholar at the Johns Hopkins Bloomberg School of Public Health. Her e-mail is mmogodi@jhsph.edu
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