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Health Essay Sample: HIV / AIDS in Pregnancy in Botswana

HIV / AIDS in Pregnancy in Botswana

Acquired Immune Deficiency Syndrome (AIDS), caused by the Human Immunodeficiency Virus (HIV), continues to be one of the most serious and devastating pandemics affecting mankind. A recent publication by Guiozzi and Black (2009) estimates that the worldwide prevalence of this disease has reached the 33.2 million mark, with 68% (22.5 million) of sufferers living in sub-Saharan Africa. While women of child bearing age are recognised to be the most severely affected sub-group in this region, they also hold the dubious distinction of being the prime transmitters of the infection to children, through mother-to-child transmission. The magnitude of this problem is reflected by the statistic that approximately 90% of the estimated 420,000 children infected with HIV annually come from sub-Saharan Africa (Guiozzi & Black, 2009). Therefore intervention programmes focussing on pregnant women are of critical importance in the effort to control the relentless spread of AIDS.

Botswana is one of the sub-Saharan African countries where AIDS continues to exert its devastating toll in spite of dedicated prevention and control programmes. This is substantiated by one of the relatively few published studies focussing on HIV counselling and testing of pregnant women in Botswana. The study, conducted in 2001, which involved a nationally representative sample of 4,494 women accessing antenatal-care services, reported that, despite registering a 79% rate of consent to HIV testing when it was offered, only 21% actually underwent the test. It concluded that limitations in the capacity to provide voluntary counselling and testing to all pregnant attendees of antenatal-care was one of the biggest challenges in an environment of increased patient uptake of services (Rakgoasi, 2005).

This essay outlines current the global and regional outlook of the epidemic (its epidemiology and disease burden), before considering the factors that contribute towards its spread. This will be followed by a discussion of current prevention and control programmes and a review of policy, before concluding with what could be done to effectively control the manifestation of HIV/AIDS in Botswana, with particular emphasis on pregnancy. Wherever feasible, the contents will be substantiated with evidence from published literature.
While the worldwide epidemiology of HIV/AIDS is well established, there is a relative paucity of published studies describing the situation specific to Botswana. In comparison, the situation in neighbouring South Africa is well documented. One such study focussing on the burden of disease (Johnson et al, 2007) estimated that in the year 2000, 26% of all deaths in South Africa were attributable to sexually transmitted infections, over 98% of which were due to HIV/AIDS. While reporting that the HIV/AIDS related morbidity and mortality rates had increased significantly since the year 2000, the study concluded that 2.5 million AIDS-related deaths could be prevented by 2015, if high levels of access to antiretroviral treatment could be achieved in South Africa. A valid indicator of the corresponding situation in Botswana would be that the African Comprehensive HIV/AIDS Partnership (ACHAP) estimated an adult HIV infection prevalence of 38.5% when it commenced activities in the year 2000 (Ramiah & Reich, 2006).

It is acknowledged that a sound understanding of local epidemiology is of paramount importance in formulating prevention and control programmes for any disease. The importance of this in relation to HIV/AIDS was underlined by a study in south-eastern Botswana (Livingstone, 2004), which found that the native population experienced the epidemic as a noticeable transition in disease patterns whereby the prevalence of chronic, debilitating illness had increased, despite an overall reduction of acute infectious diseases. The researcher concluded that neither the Tswana medical sector nor the national health system had fully appreciated the fact that the impact of the disease on the local population was markedly more chronic in nature (as against the worldwide focus on an acute, infectious disease), causing thereby a significant inability to grapple with issues presented by widespread chronic illness. This was suggested as one cause for the uneven levels of patient confidence with regard to a comparatively robust healthcare system.

Johnson et al (2007) agreed by calling for a more holistic, multifaceted approach in formulating prevention and control strategies, noting that planners must look beyond the role of unsafe sex when attributing disease burden to risk factors. That such approaches must include consideration of factors as diverse as seasonal environmental variations is highlighted by another study conducted in Botswana (Mach et al, 2009), which showed very high (above international threshold levels for emergency action) morbidity and mortality rates among children, linked to malnutrition and diarrhoea, coinciding with the annual rainy season. It is rational to expect that such large-scale disruption, even if seasonal in frequency, would impact negatively on any public health activities, especially those targeting pregnant women.

It seems rational therefore that any discussion regarding the prevention and control of an infectious disease must include consideration of non-microbiological factors that contribute to its prevalence. Among the factors that have been frequently looked at when explaining the prevalence of HIV/AIDS within specific communities/regions are nutritional deficiencies, lower socio-economic and educational attainment, co-infections such as malaria together with marginalisation and deprivation of access to healthcare due to stigmatization. The impact of each of these factors will be considered below, adducing to published literature of relevance.

Sub-Saharan Africa is affected by very high rates of debilitating conditions such as malnutrition and other opportunistic infections, which could devastate entire communities, by their own right. In this backdrop, HIV/AIDS could be viewed as a further exacerbating factor in an already bleak scenario. While the nature of the link between nutrition and HIV/AIDS has been the focus of many studies, its overriding, common-sense importance is reflected by the call for complementing antiretroviral programmes with nutritional and micronutrient supplementation efforts, especially in sub-Saharan Africa (Anabwani & Navario, 2005).

Some studies have indeed predicted the clustering of HIV to poorer communities. For example, a longitudinal population-based study in eastern Zimbabwe (Lopman et al, 2007) reported a lower incidence of HIV, and the associated mortality, within higher socio-economic groups. However, a recent review suggests that individual or household poverty is not necessarily a risk factor to exposure to HIV (in comparison to wealthier individuals/communities) in sub-Saharan Africa; conversely, suggestions of such an association may be driven by the manifest increase in the severity of downstream impact of AIDS among lower socio-economic groups (Gillespie et al, 2007). The realisation of this has led to calls adopting group-based and place-based approaches in formulating epidemiological and interventional strategies focusing on HIV/AIDS, as distinct from dominant high-risk group approaches (Msisha et al, 2008).

A series of cross-sectional surveys of pregnant women in South Africa, conducted between 2000 and 2005, concluded that higher attainment in education was not directly associated with an increased level of protection against HIV in the early stages of the epidemic in South Africa (Johnson et al, 2009). However, the researchers also noted a significant reduction in the risk of HIV infection among young women who had completed secondary level education, in comparison to those with only primary level education, concluding thereby that recent HIV prevention strategies may have proved more effective among those better educated.

One particular infection which makes a significant contribution to the high morbidity and mortality rates of sub-Saharan Africa is malaria. While a series of epidemiological studies have pointed to an independent coexistence of malaria and HIV/AIDS, some recent reports have suggested a more synergistic interaction (Laufer & Plowe, 2007). With regard to pregnant women, it is postulated that the HIV-related immune-suppression may contribute to increased frequency and severity of malarial attacks, which in turn are associated with anaemia, low birth weight and increased infant mortality (Idemyor, 2007).

One major social phenomenon that impacts adversely on attempts to control the spread of HIV/AIDS is the stigma attached to the disease, especially in sub-Saharan Africa. This is highlighted in a study conducted in Botswana by scientists from the Centres for Disease Control and Prevention (CDC), which suggested that non-stigmatizing, humane depictions of the condition, through media such as television, may help reduce the stigma (O’Leary et al, 2007). Daniel (2005) outlined the impact of the death of parents on orphans in Botswana, suggesting the most young excluded from the funerals of their parents, making them ‘structurally invisible’, while others are forced to adapt to a marginalised, socially unacceptable role in society.

Van de Spuy (2009) outlines another manifestation of this stigma, from a South African perspective, noting that fertility is a particularly valued characteristic making voluntary childlessness unusual. As AIDS is associated with a reduction in fecundity and fertility, in addition to compromising the outcome of pregnancy, female sufferers are made to experience profound deprivation of social status. Indeed, so pressing is the need to give birth to children, some who have been diagnosed with HIV/AIDS deliberately choose to ignore the risk of infecting their sexual partners, in order to ‘prove’ their fertility (Moore & Oppong, 2007). All this contributes to the relentless spread of the disease, even as it leads to further isolation and marginalisation of vulnerable women, thereby significantly reducing their accessibility to healthcare services. It is notable that a study involving nationally representative, adult samples in Kenya and Malawi, conducted between 2003 and 2005 (Anand et al, 2009), found that over 80% of those diagnosed with HIV/AIDS during the study were not actually aware of their HIV status. Only 10% of these had used condoms during the last act of intercourse.

Other suggested contributory factors linked to the HIV/AIDS pandemic in sub-Saharan Africa include increased sensation seeking behaviour and substance misuse (Kalichman et al, 2008) and genital herpes infection (Abu-Raddad et al, 2008). A study specifically focussing on risk behaviours among pregnant women in rural Kilimanjaro, Tanzania, concluded that there was no significant difference between the pregnant and general population with respect to HIV awareness or behavioural risk (Mmbaga et al, 2009).

It would now seem opportune to discuss existing prevention and control programmes from a global perspective, and from that specific to Botswana. Comparison of what is thus being offered, against the backdrop established above may then help identify improvements, if any, that may help strengthen the efforts to control HIV/AIDS in pregnancy, in Botswana.

Efforts to prevent and control the spread of HIV/AIDS have been diverse; they have also been the focus of many studies. These have ranged pharmaceutical interventions based on the use of antiretroviral therapy to public health initiatives designed to increase awareness and reduce transmission.

Botswana introduced a programme for routine testing for HIV in 2004, thereby becoming the first African country to offer this service. An evaluation of the first two and a half years of the programme published in 2007 reported widespread acceptance by the population, with no reports of adverse incidents. Testing rates had progressively increased from 40 per 1000 persons in 2005, to 93, followed by 104 per 1000 persons, through 2006 and 2007 respectively (Steen et al, 2007). The evaluators credited the programme with an increase in the use of preventive services together with earlier assessment for antiretroviral therapy. This appeared to substantiate the conclusions of an earlier study, conducted among HIV clinic attendees in Botswana, which suggested that the acceptance of testing would be high, provided it were perceived as beneficial (Talbot, 2000).

A recent review focussing specifically on efforts to control mother-to-child transmission of HIV-1 has reported encouraging findings. This report by Coovadia (2009) highlights three types of successful interventions: primary prevention targeting women, use of antiretroviral prophylaxis targeting breastfeeding infants and, thirdly, antiretroviral prophylaxis is targeting lactating mothers. However, the report also cautions that the key barriers that prevent the widespread implementation of such programmes in most developing countries are ineffectual and weak healthcare systems.

The findings of the above review are collaborated by at least one study conducted in Botswana: a recent randomised controlled trial studying the risk factors linked to early and late transmission via breast feeding in Botswana supported the implementation of a maternal and infant prophylactic antiretroviral schedule, combined with one month of breast feeding (Shapiro et al, 2009). Another reporting on the long-term follow up rates of the Botswana Antiretroviral Programme, initiated in 2002, claimed a mean pick up rate of 92.5% over the period of 5 years, with 75% of patients missing a maximum of one pick up per year. This report highlighted the achievement of excellent, and sustained, clinical, virological and immunological outcomes in the first batch of adults enrolled into the programme, with those surviving into the second year of therapy reporting markedly low mortality rates (Bussman et al, 2008).

However, studies conducted in other countries have highlighted the continued existence of barriers to achieving sustained success in controlling the spread of HIV/AIDS. These include the presentation of patients with combined pathology (especially hepatitis B and C) in Nigeria (Entonu & Agwale, 2007), and the seeming ineffectiveness of traditional approaches (such as abstinence, fidelity, condom use and needle exchange) in circumstances of major societal disruption as manifested during armed conflict in northern Uganda (Westerhaus et al, 2008).

Despite these indications for caution, there is some cause for optimism in the final outcome of the battle to control the spread of HIV/AIDS in the sub-Saharan region. Noticeable among the developments demanding further study, with a view to wider expansion, is the African Comprehensive HIV/AIDS Partnership (ACHAP) linking the government of Botswana, Merck & Co., Inc. and the Bill and Melinda Gates Foundation. A recent report on the first four years of ACHAP has highlighted several important lessons in managing high intensity public-private partnerships in the field of public health (Ramiah & Reich, 2006). Lessons could also be learned, especially with regard to the social complexities impacting on disease transmission, from other initiatives such as the Mpondombili Project, targeting school-going adolescents, conducted in rural South Africa (Mantell et al, 2006).

One other area that holds much promise, especially in view of very recent developments, is that of producing an effective vaccine against the illness. A study undertaken in South Africa, among high-risk adolescents, to establish hypothetical willingness to participate in a phrase III trial, reported mixed results, suggesting the importance of psychosocial factors in determining an eventual response (Giocos et al, 2008). A further factor cautioning against overestimating any potential immediate benefit from a vaccine is the diversity of HIV subtypes, with almost all cases in southern Africa being attributed to subtype C (HIV-1C), while the predominant subtype in United States in B (HIV-1B) (Redd et al, 2007). Coincidently, the report noted higher rates of anaemia in patients suffering from subtype C infection, prompting the recommendation for consideration of this factor when designing antiretroviral regimes in areas with predominant HIV-1C infection.

It is important to consider the impact of policy on efforts to prevent and control HIV/AIDS as part of this discussion. Such consideration is crucial in establishing the framework within which any programme would be required to function. It would also help identify the degree of political commitment to drive changes that would be imperative in tackling this epidemic.

During the initial manifestation of the disease in the developed world, the paucity of effective medical interventions, together with the desire to avoid discrimination in order to minimise the possibility of at-risk individuals from ‘going underground’, influenced the establishment of the concept of autonomy of infected, and at-risk persons, in controlling the spread of the disease. However, by the turn of the century, the introduction of effective therapeutic regimes such as the Highly Active Anti-Retroviral Therapy (HAART) and Zidovudine, prompted calls for a review of this policy of autonomy, suggesting the possibility of the implementation of more coercive measures (Harrington, 2002) as means of combating the spread of infection within the developed world.

A World Health Organisation (WHO) technical consultation exercise, held at Copenhagen in October 2006, in collaboration with the European AIDS Treatment Group (EATG) and AIDS Action Europe (AAE), considered the principle of criminalisation of HIV and other sexually transmitted infections. The participants expressed their concern regarding the singular focus on HIV for prosecutions where it was allowed (as exemplified by all 10 post-2003 prosecutions brought under the Offenses Against the Person Act, 1861, in the United Kingdom), and recommended that the potential negative impact of criminalisation on public health and human rights be granted serious consideration; they proposed that criminal law was too blunt an instrument to effectively deal with the complexities of HIV transmission (World Health Organisation, 2006).

While it has been widely recognised that any policy initiative must enshrine the human rights and the dignity of those infected by the disease, the very lack of clearly enunciated and enforced legislation, can by itself facilitate discrimination, by leaving room for selective interpretation, as demonstrated by a study in India (Elamon, 2005). While anecdotal accounts would suggest the prevalence of discriminatory practices in the southern African region, the one area that has seen relatively consistent development of related policy initiatives is that aimed at preventing violence against women.

The difficulty in establishing and implementing effective policy however, is clearly illustrated by the opposition to the passage of the Sexual Offences Act in Kenya, where it was claimed that women would be encouraged by the bill to make false rape allegations (Association for Women’s Rights in development, 2007). To their credit however, the act which specifies 14 offences, became law in July 2006. Similar difficulties in establishing policy was encountered in South Africa, a country with reportedly high levels of sexual violence, despite the national government approving a policy supporting the provision of HIV post-exposure prophylaxis (PEP) to victims of rape (Kim et al, 2003). These experiences have highlighted the importance of sustained political will, supplemented by adequate education and training, in driving the establishment and implementation of suitable policy initiatives in combating the spread of HIV/AIDS in sub-Saharan Africa.

What then could be done to strengthen and sustain the battle to control the manifestation of HIV/AIDS in pregnancy? From the foregoing discussion it would be evident that there is no quick-fix solution to the problem of HIV/AIDS, especially from the context of its manifestation in pregnancy, in sub-Saharan Africa in general, Botswana in particular. What is equally evident is that despite being hampered by a very high level of the disease burden, and considerable shortage of resources, Botswana has recorded several impressive strides in its battle to prevent and control the spread of this infection. The reported successes of its Antiretroviral Programme and the Routine HIV Testing programme, together with the maturity gained by participation in the African Comprehensive HIV/AIDS Partnership (ACHAP), would all augur well towards a positive outcome in its efforts to control the spread of the infection in general terms.

Equally, perhaps more importantly, the identification of particularly effective strategies targeting the manifestation of the disease during pregnancy provides the opportunity to design and implement sustainable programmes that could significantly reduce the disease burden, not only among women of child-bearing age, but also among the children who would otherwise be infected through mother-to-child transmission. It is vital that such programmes must be implemented universally, countering the tendency for the clustering of services towards younger, more educated women, residing mostly in towns (Rakgoasi, 2005). Moreover, the paramount importance of the need for political will, appropriate infrastructure, and suitable training and expertise development, to drive such initiatives cannot be overemphasised. Wherever possible such programmes must be contextualized to local needs, beliefs and aspirations; they must be preceded by methodical epidemiological studies and designed to generate local participation and ownership.

Considering all outlined above, what would amount to a fair summarisation of the current situation?

After a prolonged period of time when HIV/AIDS brought rampant destruction to the entire sub-Saharan Africa, countries such as Botswana now stand at the brink of making an effective advance in the battle to control the spread of the dreaded disease. While all efforts must be founded on a thorough understanding of the local epidemiological manifestations, and be holistic and comprehensive in ambition and design, there is a strong argument for special consideration of interventions during and around the period of pregnancy.

While regional political will and commitment to drive these initiatives are a pre-requisite, the entire world must unite to assist in the provision of resources and training, to implement and sustain these initiatives at this critical moment in time. In practical terms this may include the provision of training and infrastructure development, low cost drugs and commitment to further research and development focussing on the particular manifestations of HIV/AIDS in sub-Saharan Africa. If successful, it may actually be possible to limit and eventually overcome the seemingly relentless march of HIV/AIDS across sub-Saharan Africa.

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