He had been seeing all three for at least two years. He used condoms with the secret girlfriends but not with the real one. How many secret boyfriends do those secret girlfriends have? I asked. And the real girlfriend? Several other men I met had similar sexual arrangements. Botswana is a culture of migrants, where both men and women often spend time away from their homes and may have long-term relationships with different people in different places.
The traditional form of wealth is cattle, which are kept on remote cattle posts. For centuries boys tended the cattle, and men visited the herds from time to time, leaving their wives behind.
Even though Botswana is a relatively wealthy country by African standards, some 38 percent of the population is classified as poor.
The government provides rations to the destitute, but many people told me they had experienced deprivation and unemployment. Women in Botswana generally work at low-wage jobs such as housecleaning, child care, or farming. As a result, girls and women are drawn into relationships with relatively wealthy men who help them and their families. These men may have several long-term female sexual partners at the same time — one or two in their home villages and one or two in town.
Girls are particularly vulnerable. Roughly equal numbers of men and women in Botswana are HIV-positive, but the HIV rate is much higher among teenage girls than among teenage boys, although boys and girls become sexually active at roughly the same age. A study in found that 20 percent of girls in one region of Botswana had been asked by their teachers to have sex; half said they accepted, fearing lower grades if they said no.
Unlike many African countries, where government AIDS programs have been desultory, the Botswanan government is at war against the virus. Free condoms are available in remote clinics, bars, and shops. The government has also funded a Danish-run program that employs field-workers to bring the message of HIV prevention to every household. Despite these efforts, the HIV epidemic in Botswana shows few signs of abating.
Studies show that even when used consistently, condoms fail to prevent infection 10 percent of the time, due to breakage and human error. In any case, most people do not use condoms every time they have sex but only with prostitutes and casual partners.
Many people use them early in a long-term relationship but then dispense with them later on as a gesture of trust. But these long-term relationships are the very ones that Morris believes are the most risky. The solution, says Green, is for people to limit themselves to one sexual partner. A report from the United States Agency for International Development says the number of men with casual sexual partners fell from 35 percent in to 15 percent.
In many places where HIV rates have fallen, widespread behavioral change has been accompanied by extraordinary activism. In the early s, there was a vibrant movement devoted to the fight against AIDS. Hundreds of community-based organizations and activist groups had sprung up, most run by women.
VMMC is also regarded as a good approach to reach men and adolescent boys who do not often seek health care services. Since the WHO recommendation for VMMC as an additional prevention strategy, over 23 million adolescent boys and men in the 15 countries have been circumcised and provided a package of services including HIV testing and education on safer sex and condom use.
More than 10 randomized controlled studies have demonstrated the effectiveness of PrEP in reducing HIV transmission among a range of populations including sero-discordant heterosexual couples where one partner is infected and the other is not , men who have sex with men, transgender women, high-risk heterosexual couples, and people who inject drugs.
WHO recommends PEP use for both occupational and non-occupational exposures and for adults and children. People who inject drugs can take precautions against becoming infected with HIV by using sterile injecting equipment, including needles and syringes, for each injection and not sharing drug-using equipment and drug solutions. Treatment of dependence, and in particular opioid substitution therapy for people dependent on opioids, also helps reduce the risk of HIV transmission and supports adherence to HIV treatment.
A comprehensive package of interventions for HIV prevention and treatment includes:. MTCT can be nearly fully prevented if both the mother and the baby are provided with ARV drugs as early as possible in pregnancy and during the period of breastfeeding. Several countries with a high burden of HIV infection are also progressing along the path to elimination.
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News from countries. WHO delivers 6. How a commercial driver is contributing to prevent the spread of Covid in Kumasi in the Ashanti Region of Ghana. WHO emergency teams learning and supporting in Malawi. Accountability » Financial reports General Programme of Work. The Transformation Agenda ». Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection In addition, one in three people living with HIV presents to care with advanced disease, low CD4 count and at high risk of serious illness and death.
Key fact 1. Oral PrEP taken once a day can reduce vulnerability to infection by 99 percent. In areas where there is so much HIV circulating, every sexual encounter is high risk, and widespread PrEP could be a prevention lynchpin.
However, PrEP rollout has been slow and inadequate in South Africa since it was approved in national guidelines in There have been issues with messaging, health worker sensitization and training, and availability.
PrEP scale-up will require extensive outreach to create demand, ensure adherence, and negate any stigma to ensure that all those at high risk can have access. Only an estimated 12, people are currently on PrEP at approximately 50 clinics nationwide—shy of the national target of more than 18, To put that in further perspective, 12, equates to only 5 percent of the , presumed to be at risk for new infections based on the rates. The most recent national survey data from shows the same low level of condom use among year-olds as the last survey in , an increase in sexual debut before the age of 15 for boys, and an increase in multiple sexual partnerships for women under One barrier is the provision of basic health education and service delivery in schools.
While South Africa has a national policy on school-based health education, some provincial officials, school governing boards, and other gatekeepers often prevent services from being provided, even though the age of consent for health services is Schools are an important entry point because there is a high rate of school retention in South Africa and, once out of school, it is difficult to reach young people. While we met many dedicated HIV champions across South Africa, and there are commitments from national and provincial officials and existing national strategies, the health and education systems are not providing the necessary information and services for young people, and not enough investment is being made to empower communities and civil society organizations to launch more effective and sustainable responses.
There is an absence of targeted outreach, media campaigns, and high-profile champions. Young South Africans told us repeatedly that they wanted more leadership and information on HIV and to see role models of healthy living that make HIV prevention and staying negative cool and demonstrate how to live positively with HIV. The critical gap in South Africa is not between evidence and policy, but between policy and implementation.
While the government is committed to supporting the national HIV treatment program and has issued enabling guidelines, it faces significant challenges to effective implementation. It lacks the resources for an overhaul of the public health infrastructure and to scale up and increase coverage of prevention programs like PrEP and broader programs to address the needs of young adults.
In addition, health worker shortages and a rising non-communicable disease NCD burden are crippling already overstretched health facilities, and the decentralized health system requires political will at the provincial and district levels to implement services effectively.
Many politicians and local government officials are preoccupied with other issues, such as the economic crisis that has gripped the country in recent years, a legacy of corruption that has crippled the energy sector, and upcoming elections in May.
After the elections in May, there is an opportunity for the government to re-commit to fighting HIV, at national, provincial, and district levels. The characteristics of sexual networks especially determine the extent and rate of spread.
Specifically, female sex workers and male clients are at high risk for infection and have been instrumental in starting the AIDS epidemic in sub-Saharan Africa.
These men with multiple sex partners then transmit HIV to women in the general population. The presence of other sexually transmitted diseases and the lack of male circumcision may increase the probability of HIV transmission during sex and are probably partially responsible for the rapid diffusion of HIV in the region. Preventive interventions are needed among high risk groups and within the general population. Epidemiologic, behavioral, operational, and evaluation research are needed in order to design and implement programs which are most appropriate and effective in changing behavior.
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