Haleigh Gulden

HIV/AIDS In Botswana

May 17th, 2017

Botswana, a landlocked country is directly north of South Africa and nestled

between Namibia, Zimbabwe, Zambia and Angola. Botswana prides itself in being one of

Africas most stable countries holding the continents longest continuous multi-party

democracy and is known for being relatively free of corruption, with a good human rights

record. Unlike many African countries exploited by other higher income countries for

their natural resources, Botswana after gaining independence discovered diamonds and

was able to use trade to transform itself into middle-income nation, investing in education

and infrastructure.

While Botswana has had much success in its nation and democracy, the country

has its share of challenges, once having the worlds highest rate of HIV/AIDS prevalence

in the world. In 2014 the United Nations estimated that the prevalence rate of infection of

people between the ages of 15 to 49 was 25% and not much has changed today. HIV

stands for human immunodeficiency virus and left untreated leads to AIDS or acquired

immunodeficiency syndrome leading to death. Once one has contracted HIV the human

body can never get rid of the virus.

What exactly is HIV/AIDS and how does it work?

HIV attacks the bodys immune system, and more specifically the CD4 cells (T

cells). These cells are the ones in which help the immune system fight off infections.

When left untreated, HIV reduces the number of CD4 cells (T cells) in the body, making

the person more susceptible to infections or infection-related cancers. In sub-Saharan

Africa this is often TB. Over time, HIV destroys so many of the T-cells that the body

cant fight off infections and disease. These opportunistic infections or cancers take

advantage of the very weak immune system, signaling that the person has AIDS, the last

state of HIV infection. No effective cure for HIV currently exists, but with proper

treatment and medical care, HIV can be controlled. The medicine used to treat HIV is

called antiretroviral therapy or ART. If taken the right way, every day, this medicine can

dramatically prolong the lives of many people with HIV, keep them healthy, and greatly

lower their chance of transmitting the virus to others.

AIDS is the final stage of HIV, occurring when an immune system is badly

damaged and become vulnerable to opportunistic infections. When the number of your

CD4 cells falls below 200 cells per cubic millimeter of blood (200 cells/mm3), you are

considered to have progressed to AIDS. You can also be diagnosed with AIDS if you

develop one or more opportunistic infections, regardless of your CD4 count. Without

treatment, people who are diagnosed with AIDS typically survive about 3 years. Once

someone has a dangerous opportunistic illness, life expectancy without treatment falls to

about 1 year. People with AIDS need medical treatment to prevent death (WHO 2004).

During 2014, an estimated 39.9 million people worldwide were infected with

HIV, 69.9% of whom lived in Sub-Saharan Africa. AIDS-related deaths have declined by

an estimated 42% since its peak in 2004, however the burden of disease continues as

ART enables many people to live 20 to 35 years after commencement of treatment, in

part by decreasing the number of opportunistic infections such as tuberculosis. In

Botswana, the rate of vertical HIV transmission has declined from 30% before the

implementation of preventative ART programs to 3.9% in 2008 and to 2.1% in 2013 with
an estimated 320,000 people living with HIV and 213,953 on ART (National AIDS

Coordinating Agency 2014).

In 2011, according to Botswanas Ministry of Health, a total of 165,701 patients

were on highly active antiretroviral treatment (HAART). The government implemented

programs to help address the HIV epidemic. Some of these endeavors include behavior

change information and communication, preventative measures of vertical HIV

transmission, routine HIV counseling and testing, multiple concurrent partnership

counseling, safe male circumcision, home-based care programs and ART

(Skivington&Standge 2010).

One of the challenges associated with ART and other forms of medication

treatment is the serious side effects that can adversely affect a persons quality of life.

While ART has major benefits including stopping or even reversing disease progression

and therapy prolonging a persons life, a person with troublesome physical symptoms

may opt out of treatment as ART implies lifelong treatment adherence. There is limited

data on the prevalence of Batswana patients who have undergone ART for five years or

longer, thus making it difficult to determine the number of individuals who have stopped

taking medication due to adverse symptoms. (Ramiah& Reich 2005).

HIV/AIDS, Men and Gender Norms

It is important to be inexpressive, to have secrets, which you keep to yourself.

If you are a man who is worth his salt, every business of yours should not be known to

everyone, to the extent that you take some of them [secrets] to the grave with you when

you die. We know that women cannot keep secrets. (Man, 34 years, university) In the

cases of the focus groups, They realized for the first time in their history that the blind
pursuit of certain idealized masculinity norms, such as multiple partnerships and risk-

taking through non-use of condoms, could result in infection and death.. And for many,

they would rather not know, preferring to be struck down suddenly with illness and

make a quick exit without causing a fuss.' A discussant offered a narrative about how

his friend developed cold feet when he was supposed to be tested for HIV.

(Rakgoasi&Odimegwu 2013)

The dialogue and case study above is one of many that took place in a focus group

in rural Botswana for the purpose of researching gender roles, specifically of men in the

study of the spread of HIV. The statement above is problematic and tells provides a

snapshot as to why Botswana is struggling with HIV/AIDS today. In this statement alone,

we can begin to see the repercussions of unhealthy gender roles; it is unmanly to tell

people, particularly women of their illness or to seek medical care. This social norm not

only posses a threat to the men of whom are infected but also their sexual partners. Men

neglecting to tell their sexual partners of their illness speaks to the hegemonic culture

perpetuating biopower of unknowing female bodies.

Batswana leaders are aware of the problematic nature and cultural norms around

gender norms and the spread of HIV/AIDS. In President Festus G. Mogaes Narrative of

Secular Conversion focusing on Health Communication, President Mogae speaks to the

display of hegemony and gender norms displayed in the case study above. He noted that

men in Botswana had come to be associated with actions that only serve to compound

the problem. Issues of gender-based violence including murder, rape, incest, sexual

abuse, and denial of reproductive health are perpetrated by men.. President Mogae goes

on to state, reasoned that men who valued their own individual desires over the health
and safety of others were contributing to the spread of HIV/AIDS and, in this way, were

creating an unsafe, unhealthy environment for everyone, including themselves. Their

self-interest ultimately worked against them (and others) and thus had to be replaced by

another god-term.. (Holyoak&Shorter 2012)

Condoms and Traditional Culture

The history of policies, western influences, social norms and ideals are important

in considering and comparing deep-rooted issues with social norms and stigma of today

regarding HIV/AIDS. This is something publicly acknowledged as President Morgae

claims the disease as rooted in past values. One thing we have to learn in account of

policy is the failure of Western-inspired approaches in dealing with the pandemic.

Botswana is an interesting case to focus on here because its programmes to combat

HIV/AIDS have from the beginning, in the late 1980s, taken their lead from international

expert advice. By not taking into account the cultural and institutional features, such

ideals have created resistance to the messages and inhibited effective implementation.

The negative response to the first educational campaign stressing condom use is

described and contextualized in terms of Tswana ideas of morality and illness. It was

thought that free ARV therapy would break the silence and stigma that developed around

the disease, however it would not turn out to be the case.

There are many and have been many international organizations that have been

called to action in Africa around the HIV/AIDS epidemic. While some examples of these

include PEPFAR, UNAIDS, Global Fund, and the Clinton Initiative dedicated to

combatting HIV/AIDS, there remains a searing gap between intention and result.

Measures that have been advocated for in Africa have proven to be less effective than
would be expected. One contributing factor is the underutilization of anthropological

forms of understanding. Anthropologys contribution to the research on HIV/AIDS may

be said to be largely a critical one, pointing to the gaps in the policy, its lack of local

responsiveness, and its neglect of important social and political contexts that create

populations vulnerable to the disease. (Farmer)

In synopsis, when Western influences on the HIV/AIDS crisis and initiatives

came about, there were unintended consequences of their initiatives that perpetuated

taboo, especially with Tswana beliefs as it was contradicting. In the 1988 a mass

educational campaign was launched with the condom at the center of this message.

Many people did not have any knowledge of the disease, so hearing of its morbidity or

mortality seemed preposterous, and in tern was referred to as the radio disease.

Further, in addition to the initial disbelief, there was outrage as the promotion of a

barrier method to prevent infection set up the cry of immorality, of encouraging

promiscuity. Consequently, it met the resistance of churches, parents and the

population in general.

This disbelief of the facts and the opposition in terms of morality fed in and

fuelled an alternative discourse of AIDS.In this discourse AIDS is not seen as a new

disease but as an old one, a manifestation of old Tswana ailments, grown more virulent

in response to the disregard for the mores of traditional culture. In other worlds, it was

thought that AIDS manifests itself not as a new disease but as a mass of old ones. The

association of AIDS here is not with disease per se but with pollution, consequent upon

the breaking of prohibitions which ideally control reproductive life. These proscribe

sexual contact at various times, most particularly during menstruation, following birth or
 miscarriage and after death. This is based on an elaborate and coherent bio-moral

theory. Sexual intercourse has an especial value, not just because of its procreative

power, but because it creates connection, a flow of bloods, between legitimate sexual

partners. This is deemed health-giving in itself and of this is that the condom could be

seen as designed not to prevent infection but as an agent in its origin and spread. In

stopping such flows, it was interpreted by traditional doctors and the leaders of spirit

churches as a vector of ill-health and disease (Held 2006)

Instead of tacking stigma it actually ended up othering people with HIV/AIDS

with shame, giving them a special status that was then associated with perverted

sexuality thus perpetuating stigma and creating social barriers to seeking treatment. By

advertising AIDS as a distinct kind of disease of which required strict confidentiality it

perpetuated the virus as something that is shameful and taboo. We have much to learn

from this instance as it tells us that we must, at the very least, take into account cultural

norms, teachings and religions into advertising, education and public health tactics in

order to even have the chance at being successful.

Even better, it should be considered of greater value to work with a community

instead of at them. If there had been a focus group of community members and if western

professionals had talked to the communities they were attempting to serve, this

perpetuation of stigma today would not be what it is. If Western professionals would

have taken into account and brought in the community to work with them, then branching

out, the rate of HIV/AIDS may have been much lower in Botswana then it is today. From

this, as people from western countries we must understand that while we know a lot and
can bring something valuable to communities, we also have a lot to learn. In order to help

we must first listen to the needs and to the people in which we intend to serve.

In conclusion, the prevalence of HIV/AIDS in Botswana is not in majority

because of a lack of life preserving drugs but because of social stigma and othering of

those infected. A major contributing factor of the stigma associated with HIV/AIDS

could have been prevented if the Western experts would have taken into account the

culture, religion and norms of the people. If these said experts would have worked with

and in communities instead of at them, community education could have been culturally

appropriate and thus could have worked with the culture, norms and religious stands

instead of against.

I suspect that if these outsiders would have had focus groups with the

communities in which it intended to serve, if they had talked with anthropologists on the

topic I would venture to guess a different approach would have been taken and that

HIV/AIDS would not be what it is in Botswana today. While I understand the wanting to

push for condom usage, the message could have been framed differently, not having

condoms at the center but as a if than statement plugged into the message or with a take

to normalize condom usage. Instead of framing condoms usage for only people with more

that one sexual partner, normalizing condoms and framing it as, if you are having sex and

are not trying to get pregnant, it is healthiest practice to use a condom. Helping Batswana

people not get rid of but adjust their cultural and religious takes on the flow of bloods

and debunking the myth of condoms being a vector of ill-health and disease would

have likely proved more helpful.

 I think it is important to be mindful that while it is true that Western experts could

have done and should have done a lot better at their job, it is also important to understand

that this is much easier to see now as a student forty years later. This incident should not

have happened but it is now what we are learning from today. With this we should be

mindful of the fact that we very well could be making similar mistakes in a sense that

forty years from now we could be shaking our heads at actions seen just as arrogant.

Being mindful and humble can help us detect unintended consequences and change them

before there is great cost.

Citations:

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Held, S. (2006). ABSTAIN OR DIE: THE DEVELOPMENT OF HIV/AIDS POLICY IN

BOTSWANA. Journal of Biosocial Science, 38(1), 29-41.
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Rubric:
1. Introduction to the country of Botswana
2. Introduction to HIV/AIDS
a. What is HIV/AIDS
b. How does it relate to Botswana
3. HIV/AIDS, Gender norms and Stigma with Men
4. Condoms and Traditional Culture
5. What To Learn and Take Away