George Strait: So give me your name and tell me your role in Botswana with this fight against HIV.

Ernest Darkoh: My name is Dr. Ernest Darkoh (MS?). I’m the operations manager for the Ministry of Health Antiretroviral Project Team.

George Strait: Tell us something about what’s going on in Botswana, especially around antiretrovirals. It’s different from other countries, correct?

Ernest Darkoh: Yes, it is. I think what’s different about Botswana is the scale, scope and magnitude of the -– and aspiration of their antiretroviral initiative. The initiative is to provide free-of-care antiretroviral therapy nationwide. So this is a blanket program, unlike other countries. I think that most African countries at the moment, where -- although many of them have the initiatives that are ongoing, they’re usually, you know, pay-as-you-go-type system or, you know, fee-for-service- type of provision of antiretrovirals. Whereby individuals who can afford it get the medication. In Botswana, the government is actually planning on providing medications free to our qualifier vis-à-vis certain criteria.

George Strait: What’s special about Botswana that allows it to do this, both aspirationally and financially?

Ernest Darkoh: I think what’s special about Botswana is that the leadership, I think, is courageous. They’ve taken the courageous stand do this. But also, this has been backed up by, I think, a very strong, you know, politically stable system, and also a very strong economy.

Botswana at the moment actually has I think one of the best economies -– definitely the best economy in Africa, a high credit rating, better than Japan at the moment, has reformed reserves. And I think with also in the backdrop, with a backdrop against which they thought that they could make this decision to pursue antiretroviral therapy.

George Strait: So I mean, part of this has to be not just sort of a moral imperative, but the credit rating and all of the economic gains that Botswana has made over the years, I guess they feel threatened?

Ernest Darkoh: Exactly. And rightfully so, it should be. Botswana still is largely a commodity-based economy. Beef, diamonds, tourism. These require people and specialized skills. And especially given the particular demographic that HIV/AIDS knocks out of your population, Botswana’s actually in a very serious and critical situation because it does need people to actually -– these people are the engine of its economy. And they’re the ones who are being knocked out. So therefore the country has to act.

In addition, in terms of actual numbers, Botswana is very small. It actually can’t afford to lose people. We’re not talking about Nigeria with a population of 120 million. This is 1.7 million, as its 40% of adults are HIV positive. It’s problematic when you look at it from that perspective. And the predictions are dire if this proceeds unchecked.

George Strait: So when did the plan actually get started? And what do you hope to do? Ernest Darkoh: The plan began actually -- in earnest, it began in June of 2001. And it began basically with a feasibility study to determine whether the government could indeed, you know, pursue antiretroviral therapy and make that a reality in Botswana.

In terms of real work, in terms of physically implementing the program on the ground, began in January of this year. And basically, the aspiration is to set up the drug procurement stores and distribution systems to establish a very strong communication network about the program, doing the information education, communication, and community mobilization to implement a national IT system to track and manage patients, to implement lab and testing infrastructure nationwide, also to procure the necessary space to treat, counsel, and support patients.

George Strait: So you’re building a whole infrastructure?

Ernest Darkoh: Basically, we’re building a whole infrastructure. Not to mention, of course, a very important issue of recruiting, retaining and training staff, which is forever a challenge of unprecedented proportion in Botswana. Where, as I mentioned, you know, we have staff who are being knocked out by the disease, as well as in the context of the situation where you already have chronic shortages. So it’s a challenge.

George Strait: And I know that it’s new, but what’s been the reaction of the people who live in Botswana? There’s an awful lot of stigma that’s usually associated with HIV.

Ernest Darkoh: The stigma is one of our greatest challenges on this side of the population. I think we’re looking at a people who previously were living in a contextual reality in which HIV – a diagnosis of being HIV positive was a death sentence. Now we’re offering them hope and saying that there’s antiretroviral therapy, but it’s new.

And I think we will take the loss of the mindset to evolve, you know, that people feel comfortable to come forward, you know, after -– especially once we’ve demonstrate benefits of treatment. With that said, a diagnosis of HIV/AIDS is still very stigmatizing, still very alienating, still leads to rejection, still leads to very intense, you know, emotional pain on the part of those infected and those affected by it. It surrounds them. And therefore, it remains a continuous challenge to try and get people to now get to know this data, especially before it’s late.

What we are seeing currently is a situation whereby most people actually come to the hospital when they’re very sick already because of stigma. And it’s only that, the severity of illness, that acts as a motivator to bring people in.

But at that point, often the therapy -- it’s too late for it to be truly effective. So we really need to enforce people to come in earlier. And we’re hoping now that the availability of antiretroviral therapy will be a stimulus to people coming forward and knowing their status earlier.

George Strait: So in some sense, it’s a supply and demand problem. You’re building it, but really, will they come?

Ernest Darkoh: Exactly, exactly. And I think this is the reality of the situation that we’re in. We’re supply- constrained as well. That is a fact, because we’re trying to build up as rapidly as possible, especially in the face of the staffing shortages that we have across the system.

With that said, there’s also issues on the demand side, which also are keeping people from coming forward. And ideally, build the supply side as quickly as possible, so that we can stimulate more increase in demand from the side of the population to come forward for treatment.

George Strait: But as the Minister of Health said, you can’t afford to fail.

Ernest Darkoh: Failure is not an option.

George Strait: Thanks. I appreciate it.