Evaristo Marowa, UNAIDS Country Coordinator for Botswana, said today that major opportunities to prevent HIV, and save billions of dollars in the long run, will be missed if the US and the international community fail to increase AIDS funding for Botswana and other countries in southern and eastern Africa.
He made his comments in a presentation at the Global Health Council, where he also provided a powerpoint: Botswana HIV epi and responses. Dr. Marowa’s presentation comes as global AIDS advocates anxiously await next week’s release of President Obama’s budget proposal. His urgent warning about the danger of donors adopting a flat or near-flat funding approach provided an interesting counterpoint to last week’s CSIS publication on HIV prevention, which did not mention the need to increase funding in its recommendations to the US government.
Dr. Marowa is a physician with a specialty in dermatology and sexually transmitted infections (STIs). He trained at Universities in Harare, Kinshasa, Liverpool and London. Since September 2006, he has been the UNAIDS country coordinator in Botswana, and previously he worked in Tanzania, Zimbabwe, and Bangladesh.
HIV prevalence in Botswana has fallen in recent years from 38% to 24%, with declines seen particularly in young people. The country has had strong leadership on the issue at the highest levels, which Marowa called “visionary and committed.” Prevention of mother-to-child transmission has been “an astounding success,” with a transmission rate of about 4%. A large proportion of people have been tested for HIV, about 60 to 70%, and access to antiretroviral medications is also high at about 85%. PEPFAR has been a major support to these programs, providing about $90 million a year.
However, he said that a high degree of internal mobility in the population, multiple concurrent partnerships, low rates of male circumcision, low condom use, and high rates of gender-based violence, which form the basis for an ongoing HIV/AIDS crisis. Marowa also cited alcohol abuse as a contributing factor, an issue on which he said the current president was very active.
To get ahead of the epidemic, Dr. Marowa emphasized the need to expand prevention services, including male circumcision. Circumcision has been shown to reduce the chance of a male acquiring HIV infection from a female by about 60%. It also has been found to provide several other health benefits, including reducing the risk of contracting herpes simplex virus type 2 (HSV-2), human papillomavirus (HPV), invasive penile cancer, urinary tract infections, syphilis, chancroid and cancer of the cervix in female partners.
He said that about 10% of men in Botswana have been circumcised, but he said this is probably an overestimate. Marowa said the procedure is widely accepted among men, and in fact there is a long waiting list for the procedure. The country’s leadership is on board with ramping up circumcision campaigns, yet, he said, a key limiting factor is the lack of resources for personnel and other costs.
Botswana has a plan in place called Vision 2016, which commits the country to reducing HIV prevalence by 50% by 2016. This plan includes, in addition to circumcision, the reduction of concurrent sexual partners. Marowa said that PSI is a key partner in Botswana taking this work forward, and he said it needed more funding. He said a significantly scaled-up prevention effort in the region would save billions of dollars by averting the need for ARV treatment.
He cited collaboration with PEPFAR on issues affecting refugees and migrants (who are not eligible for the government’s free ARV treatment), as well as preparation of the PEPFAR partnership framework. UNAIDS is on the steering committee for the preparation of the partnership framework, which is now in draft form.
Botswana has historically not been a major Global Fund recipient. He said UNAIDS is also working with PEPFAR to strengthen the Country Coordinating Mechanism, which prepares the applications for Global Fund resources.
UNAIDS in Botswana is also working to improve measures of new HIV infections (HIV incidence), which has been a challenge, and it is in the process of finalizing a Know Your Epidemic Study.
Another major challenge, he said, is the lack of data on HIV prevalence among men who have sex with men, sex workers and prison inmates. He said UNAIDS was working closely with the US Centers for Disease Control to improve disease surveillance.
He said the needs of MSM are included in the national framework that guides the AIDS response, yet there have been problems getting legal registration of civil society groups that represent MSM.