Botswana

Histoires vécues

Botswana: Summoning the courage: Prevention of Mother-to-Child Transmission (PMT

© UNICEF/HQ01-0207/Giacomo Pirozzi

A woman health worker wearing gloves tests vials of blood for HIV behind a glass barrier, at a laboratory of a hospital in Gaborone

Dineo Thebe (name has been changed) is a 32 year single mother of two - a 13 year old boy and a little girl born in February 2000, called Boineelo (meaning "surrender"). Dineo and her children live with her family in Tlokweng, a suburb just 20km South of Gaborone. She works as a cleaner and messenger.

Dineo took an HIV test in 1995 because she was unwell and wanted to find out what the cause of her persistent skin rash and dry cough was. She had heard a lot about HIV/AIDS, mostly from the radio and people in her community referred to it as the "radio disease". She "summoned the courage" as she put it, to approach a government centre for an HIV test. Her worst fears were confirmed when two weeks later she went for her results and learnt that she was HIV-positive. Asked about her family's response to the results, Dineo suddenly looks very anxious. "I dare not tell my brothers and sisters, I am scared of what they would say." She stood up to have a glass of water to "help me with the cough," she explained. As she sits down she looks away from me and as if talking to herself, she murmurs, "I only told my mother. But she does not seem to understand what I am saying. You see she is old." Asked about her partner, the baby's father, Dineo says she has not told him either. Apparently he abandoned her and the baby when Boineelo was just a few months old.

Dineo learnt about the Prevention of Mother-to-Child Transmission (PMTCT) when she was attending antenatal clinic in Tlokweng. The nurse encouraged her to transfer to a clinic in the city where PMTCT was offered.

Botswana began piloting the feasibility of a short-course regimen of AZT for the reduction of mother-to-child transmission of HIV in April 1999 in two cities - Francistown and Gaborone. Drugs are provided to HIV-positive expectant mothers based on a 6-weeks' course of treatment. The programme has since been scaled up to cover all districts.

© UNICEF/HQ01-0170/Giacomo Pirozzi

The gloved hands of a health worker handle a vial of blood tested for HIV at a laboratory of a hospital in Gaborone

UNICEF has been the key agency in Botswana advocating since 1997 the need to give PMTCT priority in government plans. The Government fully integrated the programme into antenatal clinic services in September 1998, allocating an initial annual budget of US$ 3.5 million for this programme. UNICEF supported all the major areas of the programme - planning, coordination, advocacy, resource mobilisation, counselling, HIV testing, community mobilization, infant-feeding and monitoring and evaluation, and continues to provide technical expertise in training at district level.

At the Gaborone clinic Dineo was informed that she would start the therapy at 36 weeks. However, she went into early labour at 34 weeks and was therefore given AZT at that point. (AZT was provided by UNICEF to pilot projects through a Glaxo Wellcome donation until the end of 2001). Her baby was given "the syrup" form of AZT for four weeks. Dineo was advised not to breastfeed and she was given formula for 12 months for the baby.

This advice runs counter to UNICEF/WHO policy which advocates for mothers to make their own informed choices. UNICEF would normally advise six months' exclusive breastfeeding on the basis that the risk of HIV transmission to a baby through breastmilk is several times less than the risk of a baby dying from a lack of exclusive breastfeeding, through contamination from unsafe water itself or if mixed with formula.

However, the Government of Botswana argued that its very high development levels - including almost nationwide access to safe water - allows for it to obviate the risks of contamination through water, just as in the developed world where formula would be the preferred option. In this way, they argued, both risks are almost eliminated.

UNICEF accepted the Government's argument on condition that this approach be continuously assessed. Initial findings after two years suggest 80 per cent uptake and adherence to the Government guidelines and no difference in infant illness or growth potential has been noted.

For Dineo, there were pressures relating to formula feeding since breastfeeding had always been promoted in Botswana - formula feeding can be a give-away of one's HIV status. Luckily the pressure was not too much - she could ward off suspicions by saying that she had problems with her breasts.

Boineelo, the baby, is doing well and her mother is taking her for monthly weighing at the clinic. Asked what her one dream for her daughter would be, Dineo thinks long and hard and asks me, "Just ONE wish?" "Yes ONE," I responded. Her answer comes after what seems like an eternity. I suspect she needed all the time in the world to select "just the one wish" out of all the many wonderful things that every mother ever wishes for her young ones. "In March 2002, I want to go to that clinic and be told that my baby has escaped this terrible disease - that's my wish." Boineelo will be 18 months in March next year and the sister had explained to Dineo that it is only then that an HIV test could be done to ascertain whether or not a baby, whose mother enrolled in PMTCT, had eluded the virus.

Botswana has the fastest-growing, HIV-infection rate and the highest rate of HIV prevalence in the world, with some 28 per cent of its total population of 1.6 million estimated to be HIV-positive. In the face of this epidemic, the Government of Botswana has taken an aggressive stance, allocating substantial human and financial resources to the fight against HIV/AIDS. In December 2001, it announced a further extraordinary measure: the availability, free of charge, of anti-retroviral therapy to everyone who is HIV-positive as of the beginning of 2002, including mothers on the PMTCT programme.

Dineo is now a member of a support group for people living with HIV/AIDS. Although she has not disclosed her HIV status publicly, she meets other members for support and information sharing. She finds the group interaction very useful and wishes that other pregnant women in Botswana could have access to this support.