The Botswana Network on Ethics, Law and HIV/AIDS (BONELA) applauds Members of Parliament (MPs) for pressurizing the Minister for Presidential Affairs and Public Administration, Mokgweetsi Masisi to withdraw the draft 2010 HIV and AIDS Policy presented in parliament last week.

This move by MPs is progressive and gives confidence to the nation that they are serious about parliamentary business and their recognition that the business as usual approach will fail the people of Botswana.
Commenting on this development, BONELA Executive Director, Uyapo Ndadi said: “this demonstrated responsiveness of parliamentarians is commendable because they listened to the voice of reason. This has ushered in a new era in Botswana in the HIV and AIDS arena because if the draft policy had gone through, the country would have taken 10 steps back in its response to HIV and AIDS.”

The rejected draft 2010 HIV and AIDS Policy was presented last week in parliament without consultation with relevant stakeholders. BONELA then issued a statement to parliamentarians that gave 10 reasons why they should reject the policy.

Ndadi added; “I am impressed that BONELA’s concerns with the draft policy were taken into cognizance by parliamentarians and this gives relevance to the work we do as an advocacy organization. It is the hope of BONELA that henceforth, the necessary due diligence, through consultation will be exercised and as an organization, we are ready to offer our expertise in drafting the policy. This victory is not only for BONELA but for the army men and women who were to be subjected to the inhumane and degrading HIV testing before being considered for employment.”

Among other things BONELA’s statement stated that the nefarious policy was a far cry from ensuring the global goal of universal access to prevention, treatment and care that can only be achieved by a human rights-based approach. To this extent, the policy left out most at risk populations such as sex workers, foreign prisoners, refugees, lesbians, gays, bisexuals, transgendered and intersexed individuals, although the foreword .of the policy by Minister Masisi refers to the need to respond to challenges posed by sexual orientation.

BONELA is a national network of individuals and organizations that promotes a just and inclusive environment to ensure the quality of life for people affected by HIV and AIDS through advocacy and capacity building.

The Botswana Network on Ethics, Law and HIV/AIDS (BONELA) has followed the debate surrounding the Draft 2010 HIV and AIDS Policy in Parliament with keen interest. BONELA urges Members of Parliament (MPs) to REJECT the draft policy based on the following reasons:

  1. The policy is regressive and has since been overtaken by local and global trends surrounding the response to HIV and AIDS. It has been acknowledged world over that HIV and AIDS can only be effectively addressed by ensuring universal access to prevention, treatment, care and support. This approach allows for targeted interventions for those groups identified as most at risk populations (MARPS) such as prisoners, men who have sex with men, sex workers and refugees. 

    To this extent, the policy is irrelevant and thus impractical as it does not deal with present day challenges. Minister for Presidential Affairs and Public Administration, Mokgweetsi Masisi refers to sexual orientation in the Foreword to the policy, yet surprisingly, the policy itself is silent on the issue. 

  2. Whilst government tiptoes around the issues of MARPS, there is clearly a need for alignment as our laws have already acknowledged issues of sexual orientation (Employment Act of 2010). In addition, the said HIV/AIDS policy is divorced from the Second National Strategic Framework (NSFII), MARPS strategy and the national HIV/AIDS research agenda that clearly indicates the need to target MARPS for successful HIV/AIDS interventions. 

    Unlike the NSFII, it lacks strategic focus or direction to effectively lay values and strong direction for other national policies and even legislation. It is vague and lacking in force, we thus beg for a rigor in ensuring that this alignment is recognized and reject the piecemeal policy, if we are to achieve the Botswana Vision 2016 goal of “zero new infections by 2016”.

  3. In 2008, the Government of Botswana passed the Public Service Act which removes health status and nationality as a basis for discrimination. However, the draft policy is inconsistent with the said law in that it permits testing for HIV before employment. 
  4. Further, the use of the word “citizens” throughout the document is a concern; it is a contradiction to the principle of non discrimination on the basis of nationality and is also contradictory to the 2006 Political Declaration on HIV / AIDS commitment in which states committed to: ‘intensifying efforts to eliminate all forms of all discrimination against and to ensure the full enjoyment of all human rights fundamental freedoms by people living with HIV and members of vulnerable groups [especially foreign prisoners, refugees] in particular to ensure their access to all services, while respecting their confidentiality and privacy’.
  5. Similarly, the silence on provision of Prevention of Mother-to-Child Transmission (PMTCT) to foreign women who have children out of wedlock with Batswana men is a cause for concern. These women do not have access to prevention of vertical HIV transmission to their children, unlike children born to a Motswana woman and a foreign man. It is a contradiction of the internationally protected right to non discrimination on the basis of nationality.
  6. The policy also takes away the right to privacy of would-be army workers. This provision is not aligned to the Public Service Act. The provision also goes against the Article 15 of the African Union Charter on Human and People’s Rights that Botswana is party to, as well as the International Covenant on Economic, Social and Cultural Rights (ICESCR) that protects the right to employment. It goes against the international best practice of universal access, zero new infections and zero discrimination. In comparison, the 1998 Policy, currently under review, better addresses non discriminatory in this regard.
  7. Government has a duty of care over a prison that includes health, food, and shelter. If government fails to perform any of those duties, then they have no moral and legal authority to continue detaining inmates. 

    There is growing evidence regionally and globally that there is HIV transmission in prisons. The policy makes no such acknowledgement and in fact, the national antiretroviral (ARV) policy effectively excludes access for foreign prisoners [who are guests of the state] and it has been noted regionally that this practice is embarrassing and very regressive. 

    Botswana is urged to deport all foreign prisoners living with HIV to their countries if she is not willing to treat them so that they may access treatment and care in their own countries. Failure to treat foreign prisoners again means continued cross infection, possible development of resistant strains and it is a violation of the fundamental right to access to the highest attainable standard of healthcare, dignity and the right to be free from inhumane and degrading treatment prisoners should still enjoy like everyone else.

  8. The new body of knowledge shows that treatment is prevention as it lowers the risk of HIV transmission. In the long-run it is cost effective to prevent new infections that will require treatment if they are not prevented. For instance there are same sex sexual relations between all inmates including foreigners. 
  9. This draft policy, like the 1998 one, lacks concrete steps to show how it will inform legislation. In addition, it was not preceded by any recent consultation as the last consultation was conducted as far back as 2005 and the national response has since evolved exponentially. 
  10. Although policies are useful guidelines, we are now at a time that we need a law and it is regrettable that parliamentarians are spending time on policies that would not change the status quo and not legislating.

The Botswana Network on Ethics, Law and HIV/AIDS (BONELA) is shocked by the comments by Gaotlhaetse Mathlabapiri, the Assistant Minister of Health in parliament yesterday.

As a human rights organization, we find it baffling that a health official can be so insensitive to the plight of an HIV positive person in any setting, especially when the whole world is calling for human rights as the only approach to universal access to prevention, treatment, care and support. This is because any HIV and AIDS initiative that is not deeply entrenched in human rights fundamentals will not succeed.

There is evidence that a human rights approach to HIV/AIDS will reduce HIV transmission rates as it acknowledges the differences among human beings that make them vulnerable to HIV infection. Such interventions therefore, will ensure that attention in terms of prevention is afforded to those most at risk of contracting and transmitting HIV.
According to the Director of BONELA, Uyapo Ndadi, “the comments by Mathlabaphiri are both careless and callous as they reflect not only the position of Government on this population, but on all people living with HIV. The response to HIV/AIDS calls for progressive leadership that will think outside the box. Clearly, there is need for transformational leadership if we are to overcome the challenges posed by the HIV and AIDS epidemic in Botswana and achieve our goal of zero new infections by 2016.”

In view of the above, BONELA questions the appointment of Botswana to the United Nations Human Rights Council if it can look on whilst foreign prisoners are wasted away by HIV in their own prison facilities. 
Ndadi also said that earlier this year, the National AIDS Council was informed that a comprehensive feasibility study was being undertaken by the National AIDS Coordinating Agency, the Ministry of Health, Ministry of Defence and Security and other partners to inform HIV interventions targeting prisoners. As an organization, we are now worried that perhaps this was lip service as a decision has seemingly been made on the fate of HIV positive foreign inmates. In our opinion, the study would highlight the number of foreign prisoners in need of antiretroviral (ARV) treatment, as well as a computation of the costs involved in providing treatment of opportunistic infections (OIs) vis a vis provision of ARVs, (considering that Botswana is using generic drugs that are even cheaper to procure) and the implications thereof.

“In the absence of such evidence, the Minister’s assertion is uninformed, misleading and a mere fallacy. It costs about P180.00 to provide ARV to an individual in a month, and clearly the benefits of saving a human life and preventing infection and re-infection of citizens overwhelms this paltry amount”, Ndadi said.
BONELA wishes to inform the Minister that treating OIs, may prove more costly to Botswana as there will be a continuous need to treat the same or different OIs. Further, treating OIs does not address HIV which is the underlying factor as HIV will continue damaging the immune system of inmates in the absence of antiretroviral therapy (ART) .

Of note is the threat of tuberculosis (TB) in a prison setting. Whilst treatment is provided for TB, the latter will be infectious prior to treatment as well as two weeks after commencement of the treatment. Government is better of providing treatment to foreign inmates because once they get TB, which is an airborne disease, they will still be in a position to infect Batswana inmates. Eventually, Government will end up treating the whole prison, instead of an individual, as many opportunistic infections are highly infectious.

The argument that some inmates originate from countries where there are no ARVs is fallacious! Which countries are those and who said their fortunes will not change? Furthermore, inmates once out can fend for themselves! It is better to be sent to your country fit and healthy than dead or terminally ill!

BONELA believes that there is lack of political will on the part of the Government of Botswana. If indeed the concern is in relation to the cost, Botswana can engage external countries she has bilateral relations with through UNAIDS, Southern African Development Community (SADC) and World Health Organization (WHO) to provide treatment to save lives, whilst a viable solution is sought.

Currently, the global approach to prevention is to provide treatment to all people who are HIV positive. We are aware that there are same sex sexual relationships in prisons and Botswana is shooting itself in the foot by thinking that her citizens are protected.

In fact, a study conducted by WHO posits that treatment can be used to “…reduce HIV incidence and mortality to less than 1 case per 1000 people per year by 2016 and…reduce the prevalence of HIV to less than 1% within 50 years worldwide.”

Following release of these findings, several countries embarked on individual studies to enhance this thesis. In Botswana, a similar study is currently underway through the Botswana-Harvard Partnership in Mochudi. The study and its findings will thus be rendered redundant if there is no universal access to ART as those denied treatment may still re-infect those on treatment, creating a pool of drug resistant strains.

As the SADC and the African Union (AU), we need a holistic approach to access to prevention, treatment and care for all citizens of the continent and strive to ensure that our counterparts in the region have functional healthcare systems as it has been proven that there is high population mobility within those countries.

The Botswana Network on Ethics, Law and HIV/AIDS (BONELA) is baffled by the statement published in the Tautona Times Vol. 9 no. 18 (30/7/2011), issued by the Commissioner of the Botswana Prison Service stating that “there are no "cases of HIV positive foreign prisoners some of them terminally ill and left to die"”.

BONELA wishes to point out that this statement is a contradiction to sentiments uttered by the Acting Minister of Health during a parliamentary sitting last week to the effect that foreign inmates are not afforded antiretroviral drugs (ARV) due to the costs of providing such treatment.

As an organization we are worried about this apparent contradiction which points to a lack of transparency on the issue. 
Whilst BONELA does not dispute that policies and procedures of dealing with terminally ill inmates are in existence, as noted by the Commissioner, the issue is, whether they are being followed and if they are adequate in ensuring that an HIV positive person can restore their CD4 count to normal levels in the absence of treatment. It is perhaps high time that these policies and procedures are revised in light of the challenges posed by HIV/AIDS and in the interest of safeguarding the health and life of all inmates and society at large.

It is common knowledge that AIDS is a terminal illness and once someone is infected with HIV they will eventually die if they do not receive ARVs, whether opportunistic infections are treated or not.

In addition, Legal Officer Dikeledi Phoo Dingake said “BONELA stands by its statement that indeed there are foreign inmates that are HIV positive and not on treatment. Seven inmates have to date approached our organization and we opened files to take up their cases. In the interim, we have had to solicit for well-wishers to provide antiretroviral drugs for the urgent cases based on valid medical records.”

Currently, Botswana commences ARV treatment when one’s CD4 count is 250. However, as noted by Dingake;“one of our clients has a CD4 count of 47 vis a vis 600 to 1000 for an HIV negative person. Clearly, this situation is unacceptable as they are in urgent need of treatment, in spite of the policy and procedures which are doing nothing to restore their health” she said.

BONELA thus calls upon the relevant authorities to investigate the issue of ARV treatment for foreign inmates further and seek a holistic human rights-based approach to ensure that prisons do not become a breeding ground for HIV infections. We also believe in the global approach that recognizes the efficacy of treatment as a mechanism for prevention of new infections.

BONELA is a national network of individuals and organizations that promotes a just and inclusive environment to ensure the quality of life for people affected by HIV and AIDS through advocacy and capacity building.

The Botswana Network on Ethics, Law and HIV/AIDS (BONELA) is pleased with the announcement of an HIV prevention breakthrough via new data from studies in Kenya, Uganda and Botswana that confirm the major role of antiretroviral medicine in preventing heterosexual HIV transmission.

According to the Joint United Nations Programme on HIV/AIDS (UNAIDS), results announced on the 13th of July 2011 from two studies, reveal that a daily antiretroviral tablet taken by people who are not HIV positive can reduce their risk of acquiring HIV by up to 73%. Daily intake of both tenofovir and tenofovir/emtricitabine as preventive medicine (PrEP - pre-exposure prophylaxis) can prevent heterosexual transmission of HIV from men to women and from women to men.

The TDF2 trial, conducted by the United States Centers for Disease Control, followed 1200 men and women in Botswana who received either a once-daily tenofovir/emtricitabine tablet or a placebo pill. The antiretroviral tablet reduced the risk of acquiring HIV infection by roughly 63% overall in the study population of uninfected heterosexual men and women.

BONELA is particularly pleased with the results of the study as it will encourage more people to get tested for HIV, discuss HIV prevention options with their partners and access essential HIV services. It is BONELA’s hope that this will go a long way in reducing stigma and discrimination targeted at people living with HIV/AIDS, which has been a perpetual barrier in accessing prevention services.

A UNAIDS press statement notes that “the medicines are available generically in many countries at prices as low as US$ 0.25 per tablet. In November 2010, the iPrEx trial among men who have sex with men in six countries reported a 44% reduction in HIV transmission among those who took a daily tenofovir/emtricitabine tablet.” 

"Effective new HIV prevention tools are urgently needed, and these studies could have enormous impact in preventing heterosexual transmission," said Dr Margaret Chan, WHO's Director-General. "WHO will be working with countries to use the new findings to protect more men and women from HIV infection." 

These findings are an impetus to accelerating Botswana’s goal of achieving zero new HIV infections by the year 2016.

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