1 1 REPUBLIC OF BOTSWANA BOTSWANA NATIONAL POLICY ON HIV/AIDS APPROVED AND ADOPTED BY GOVERNMENT THROUGH PRESIDENTIAL DIRECTIVE CAB:35/93 DATED 17TH NOVEMBER PRODUCED BY: MINISTRY OF HEALTH PRIVATE BAG 0038 GABORONE. Copies can be obtained from: The AIDS/STD Unit, E1 Toro House, Gaborone West Mall
2 1 1. INTRODUCTION 1.1 The HIV 1 /AIDS 2 epidemic is one of the most important current global socio-economic and development problems. Unprecedented partnerships have been formed between countries, organisations, groups and individuals in the attempt to halt the spread of the Human Immunideficiency virus, and provide care for those who are affected. 1.2 The Medium Term Plan for the Prevention and Control of HIV/AIDS in Botswana, (MTP), has provided policy and strategic guidance for action since the inception of the National AIDS Control Programme. The MTP outlined the role of the health sector and Ministry of Health, with the support and assistance of other sectors and non-governmental organisations (NGOs), for HIV/AIDS prevention and care. 1.3 As the HIV/AIDS pandemic has evolved, knowledge about the socio-economic factors related to the spread of HIV, and its potential social, economic and development impact, has increased. This has led to emerging recognition that only a national response which engages all sectors of society meaningfuly in HIV/AIDS prevention will slow down the epidemic. 1.4 This national policy on HIV/AIDS prevention and care outlines the national response to the epidemic in Botswana. It describes the role of national leaders, various government ministries, the private sector, on-governmental and community-based organisations, Persons Living With HIV/AIDS, and individual community members, in the national response. The policy forms the basis on which a national strategic plan will be developed. Within the national strategic plan, different ministries and organisations will formulate their sectoral plans and projects for implementation. 1.5 The policy will be used to guide all actors in HIV/AIDS prevention and care, including government ministries at policy-making and operational levels, non-governmental and community organisations, parastatal and private sector organisations and enterprises, and members of the community. External support organisations providing financial and technical assistance for all AIDS-related activities will do so within the framework of the national policy. 1.6 The policy and strategic plan will also provide mechanisms for resource mobilisation and allocation, and monitoring and coordination of AIDS prevention and care activities in the country. 1 Human Immunodeficiecy Virus 2 Acquired Immune Deficeiency Syndrome
3 2 1.7 The guiding principles underpinning this policy are based on current scientific, epidemiological and medical knowledge about the distribution and transmission HIV and other sexually transmitted diseases (STD), and proven effective interventions in prevention and care. In addition, cognisance is taken of the public health rationale for respecting the human rights, privacy and self-determination of persons living with HIV/AIDS, in line with the country's constitution. At the same time, the responsibility of Persons with HIV/AIDS to protect others from infection, as well as the right of society to that protection, are taken account of. 1.8 The policy has been adopted as a code to be observed by organisations, institutions, employers, etc. Legislation will be developed as the need arises, to support implementation and compliance. 2. BACKGROUND 2.1 The first case of AIDS in Botswana was identified in 1985, and it is estimated that significant spread of HIV in the country started in the mid-1980 s. Since then, the spread of the virus in the population has been explosive, starting in urban and peri-urban areas, and rapidly extending to rural localities. HIV seroprevalence studies among pregnant women in 1992 showed a high prevalence of 12.7% in Maun, 14.9% in Gaborone and 23.7% in Francistown. Results from a similar study in 1993 indicate that more than one in three pregnant women in Francistown, between one in ten and one in five at five other urban and rural sites, are now infected with HIV. The national estimate of persons infected country-wide at this time is 92,000. These results place Botswana among the worst-affected countries in the African region. 2.2 Several factors are thought to have contributed to the rapid spread of HIV in Botswana. Among them are the extreme mobility of the population combined with a good communication system, and the high rate of other sexually transmitted diseases, the presence of which causes a manifold increase in an individual's chance of being infected during sexual contact with an HIV seropositive partner. In addition, sexual behaviour patterns which include having multiple partners, and frequent changes of partner, are accepted as the norm, and common in both urban and rural communities. Rapid urbanisation (approximately 45% of the population now live in urban areas) has led to the breakdown of traditional mechanisims for controlling social and sexual behaviour. Poverty and relative lack of power in sexual and social relations among women are also of significance. 2.3 Research indicates that the HIV/AIDS prevention activities have succeeded in considerably increasing knowledge levels about HIV/AIDS, and increasing condom use. In 1993, more than 90% of interviewed youths had correct knowledge about HIV transmission; between 80 and 90% correctly stated 2 methods of prevention and 50 to 60% used condoms consistently with casual sexual partners. The distribution of condoms through government outlets has also increased from 2 million per year in 1991 to 1 million per month in However, between 15 and 40% of sexually active young men interviewed had an episode of a sexually transmitted disease in the previous year. In addition, 40 to 50% of interviewed young men reported having had more than one sexual partner in the previous 12 months, and multi-partner behaviour among males was significantly more frequent than among females. Thus, much still needs to be done to bring about change in patterns of sexual behaviour, and increase levels of consistent condom use, enough to slow down the transmission of STD and HIV.
4 3 3. THE CONSEQUENCES OF HIV/AIDS 3.1 AIDS is a relatively new disease in Botswana, and the greatest impact of the epidemic, in new infections and deaths, is still to be experienced. Major characteristics of HIV/AIDS are as follows: - Once infected, a person remains so for life - There is at present no cure, nor is the availability of one likely to be available in the near future - There is no vaccine at present, neither is an effective and accesible vaccine likely to be available in the near future - The incubation period is very long, during which period the HIV-infected person may infect their sexual partner(s) and unborn children 3.2 The HIV/AIDS epidemic will have far-reaching effects, at household and societal levels. These will include: - Increased illness and demand for health care services among young and middle-aged adults and young children leading to an over-burdened and more costly health care system - HIV-related increase in other diseases of public health importance, particularly tuberculosis, exacerbating the rising cost of health services - Increased psycho-social stress on, and disintegration of family structures - Increased death rates among young and middle-aged adults, and children below the age of 5 years - Decrease of population subgroups of productive age - Increased sickness-related absenteeism in workplaces, and reduced productivity
5 4 - - Loss of trained and skilled human resources in all sectors of the economy - - A significant increase in orphaned children, and concomitant increase in the demand for social welfare services to meet their basic needs - An increase in the number of urban and rural poor - Slowing down of economic development 4. A MUTLTISECTORAL NATIONAL RESPONSE 4.1 The range and projected magnitude of socio-economic impact of HIV/AIDS indicate that the epidemic should now be regarded as a national crisis, and receive from each government ministry, and sector of society, the attention that such a crisis deserves. 4.2 All sectors and ministries parastatal organisations, the private sector, and relevant non-governmental and community-based organisations should therefore develop and implement their own HIV/AIDS prevention activities, with initial technical support from the Ministry of Health. 4.3 While there is neither a cure nor a vaccine against HIV which are effective, accessible and affordable, interventions for changes in social and sexual behaviour which will include the control of STDs remain the mainstay of HIV/AIDS prevention and control. The overall strategies of the national policy are therefore: - the prevention of HIV/STD transmission - the reduction of the personal and social impact of HIV/AIDS and STD - the reduction of the socio-economic consequences of HIV/AIDS-and STD - the mobilisation of all sectors, and of communities, for HIV/AIDS prevention and care 4.4 Since HIV is mainly sexually transmitted, the prevention of sexual transmission is a key component of strategies for control. It will be achieved through: - Information, Education and Communication, using different media and approaches, and aimed at different target groups, to form the basis for changes of social and sexual norms, values and behaviours which facilitate the spread of HIV in the population - the promotion and efficient distribution of condoms to appropriate population subgroups
6 5 - the control of other sexually transmitted diseases through appropriate health-seeking behaviour by the population, and efficient diagnosis and treatment by health-care providers in the formal and traditional sectors - counselling of Persons With HIV/AIDS and STD, and others, for the adoption of safer sexual behaviours and practices - the promotion of gender equality in all spheres of national and community life, to enhance women's social and economic status, and empower them for more effective participation in decision-making about safer sex - encouraging men to use their authority and power in sexual and family relationships responsibly and positively to protect themselves, their partners and families from infection, through targeted education activities. - the mobilisation of communities for their active involvement at all stages of HIV/AIDS prevention and care, particularly the problem-definition and intervention design stages. 4.5 Prevention of other modes of transmission includes prevention of transmission through blood or blood products, transmission from mother to child and transmission through unsterile instruments in traditional and modern health practices. In particular the safety of blood and blood products will be achieved through:- - the establishment of a sufficiently large pool of safe blood doners. - A reliable blood transfusion service which can guarantee safe and appropriate processing and testing of blood. - appropriate use of blood. 4.6 Socio-Economic impact of HIV/AIDS will be severe because:- - HIV/AIDS selectively affects adults in their sexually most active age, coinciding with their prime productive and reproductive years. - The incubation of HIV/AIDS is long, so its socio-economic impact will be felt long into 21st century. - The impact of HIV/AIDS extends beyond the individual, to offspring, extended family and community. - Its psychological impact and stigma can be profound on communities with large numbers of infected and dying
7 6 young adults. 4.7 Certain ministries, due to their role, expertise and particular advantage, have been identified as key ministries in HIV/AIDS prevention and care. In addition the private sector and non governmental organisations (NGO) will play important roles. The private sector is an important partner in development. The potential impact of HIV/AIDS on productivity and profits in private sector enterprises, through sickness-related absenteeism and premature death of skilled workers, is considerable. It has now been recognised worldwide that it is in the long-term financial interest of private sector organisations to invest in HIV/AIDS prevention for workers. The private sector therefore has an important contribution and investment to make to HIV/AIDS and STD prevention, as part of the protection of the skilled workforce. NGOs and community-based organisations (CBOs) have played leading role in HIV/AIDS prevention and care in many countries, Botswana included. Their particular advantage of flexibility in response and implementaiton, closeness to the community and independence make them invaluable partners in HIV/AIDS prevention and care. NGOs and CBOs have also led the meaningful involvement of Persons with HIV/AIDS in AIDS prevention and care. The roles of various agencies will be as follows, subject to the availability of national resources. 4.8 The Ministry of Health and health sector should, because of their experience in this field, be the "lead ministry" in HIV/AIDS prevention and care for some time. Their role will be: - to lead the development and refinement of strategies for prevention and care, involving other sectors, NGOs and the private sector - to provide technical support to other ministries and sectors as they develop and implement their AIDS prevention and care activities - to coordinate and monitor the implementation of multisectoral activities, including providing a secretariat for the national coordinating body for HIV/AIDS prevention and care. - to continue with the implementation of health-sector based interventions to prevent the sexual, blood-borne and vertical transmission of HIV and STD through: - Information, Education and Communication; - Control of Sexually Transmitted Diseases;
8 7 - Condom Promotion; - Counselling for Prevention - to provide appropriate health facility-based care for Persons with HIV-related conditions and AIDS, including counselling and home-based care support. 4.9 The Office of the President will provide political leadership for the national response to the HIV/AIDS epidemic, and ensure that all sectors are mobilised and become involved as is necessary. Their role will include: - Mobilising policy-makers at various levels in the different ministries and sectors, with technical support from the Ministry of Health - advocating for the provision of national public and private resources as needed for HIV/AIDS prevention and care. In addition, the following departments of the Office of the President have keyroles, as follows: - The Department of Information and Broadcasting will play an active role in information and education on HIV/AIDS and STD through the development and broadcasting of programmes, spots and advertisements on various aspects of AIDS/STD. The Department will collaborate with the Ministry of Health, NGOs and CBOs to strengthen capacity for effective public media involvement in HIV/AIDS prevention. - The Directorate of Public Service Management (DPSM) will ensure that workplace AIDS/STD education/prevention programmes are implemented for all public sector workers. DPSM will also develop policy for the management of Persons Living With HIV/AIDS in the civil service. Personnel regulations and policies which potentially contribute to the spread of HIV, such as tranfers separating spouses and families, will be implemented to reach a workable balance between provision of essential services country-wide and disruption of families. In addition, DPSM will ensure that projected attrition due to AIDS is adjusted for in human resource development The Ministry of Finance and Development Planning will: - ensure that adequate resources are made available to the various ministries for HIV/AIDS and STD prevention and care. Coordination of external support agencies financial contributions for HIV/AIDS prevention and care will also be carried out by this ministry, in collaboration with recipient line ministries.
9 8 - use epidemiological data provided by the Ministry of Health, and commission appropriate research to generate relevant data with which to make projections of the economic and human resource development impact of the epidemic, and incorporate adjustment into manpower and economic planning. The Ministry of Education will: integrate AIDS and STD education into all levels and institutions of education, starting at primary school level, and extending to tertiary and teacher training and non-formal insitutions. involve parents, through Parent-Teacher Association and other appropriate mechanisms, in discussion of schoolbased HIV/AIDS education. ensure that other services related to HIV and STD control and care are accessible to students in need Ministry of Labour, Home Affairs and Social Welfare will : - revise criteria for eligibility for destitute support to enable families caring for people with AIDS and orphaned children access to such support. - develop programmes and mechanisms for the provision of welfare support to ensure that the basic needs of children orphaned due to AIDS are met, including facilitating fostering where needed. - develop and implement AIDS prevention programmes for relevant groups within the ministry's purview, e.g. prisoners, women, youth out of school and other institutions. - develop legislation regarding the rights of HIV-infected individuals to employment, social welfare, and compensation where relevant. - ensure, through the Labour Department, that the rights of workers with HIV/AIDS are not infringed, as stipulated in the policy and any labour-related legislation that may be developed The Ministry of Local Government, Lands and Housing Will : implement HIV/AIDS and STD prevention and care activities related to the health sector, in collaboration with the ministry of Health, through the district, town and city Councils implement HIV/AIDS prevention through its extension and
10 9 outreach services for other target groups. ensure that sufficient financial, manpower and transport resources, are available for the implementation of the intensive and extensive prevention programmes needed to slow down the epidemic within available resources. lead, through District Commissioners and Councils, the mobilisation of all sectors for HIV/AIDS prevention and care at district and local levels. mobilise the community, through existing and new structures, for their involvement at all stages of the development and implementation of HIV/AIDS prevention and care programmes and activities All other government ministries and parastatals will similarly: develop relevant policy guidelines on HIV/AIDS prevention, to guide implementation of activities at central, district and local levels. plan for, and allocate resources for the implementation of HIV/AIDS prevention activities for staff, as well as for target groups reached through the ministries routine activities. consider the potential HIV/AIDS impact of all programmes and projects planned, and take measures to minimise the potential spread of HIV. implement, coordinate and monitor HIV/AIDS prevention activities. utilise mechanisms and instruments which will be developed for the coordination and evaluation of the national response to the HIV/AIDS epidemic Private Sector organisations and enterprises will: develop and implement policies and prorgammes for the management of HIV/AIDS, in line with national policy guidelines. These will include the implementation of HIV/AIDS and STD prevention education for workers, condom distribution, as well as protection of the rights of HIVinfected workers. mobilise local private sector financial and other resources for HIV/AIDS education of workers and related communities. integrate HIV/AIDS into training courses for workers and managers where appropriate. The Botswana Confederation of Commerce and Industry (BOCCIM) and the Botswana Federation of Trade unions (BFTU) will play leading roles in mobilising private sector organisations and workers for HIV/AIDS prevenion and care in the country.
11 Non-Governmental Organisations (NGOs) and Community Based Organisations (CBOs) NGOs and CBOs will: develop and implement innovative HIV/AIDS prevention and care projects and activities, in line with the priorities articulated in the national strategic plan mobilise communities for HIV/AIDS prevention and care activities which are affordable and sustainable be advocates for the involvement of various sectors of government, leaders at national, district and community levels, in HIV/AIDS prevention and care coordinate among themelves, as well as participating in national coordination activities to minimise duplication, and enhance the establishment of complementary programmes, projects and activities. 5. COORDINATION OF NATIONAL HIV/AIDS AND STD PROGRAMES AND ACTIVITIES - THE NATIONAL AIDS COUNCIL 5.1 The coming phase of HIV/AIDS prevention and care in Botswana will be implemented by many sectors within and outside government. Coordination of this multi-sectoral national response will therefore be critical to efficient implementation, and the optimal use of resources. 5.2 A National AIDS Council will be formed, whose membership will include senior officers from the various government ministries involved in HIV/AIDS, representatives of key non-governmental organisations (including persons with HIV/AIDS), representatives of the private sector, and private individuals who have demonstrated a high level of interest, concern and dedication regarding the national HIV/AIDS situation. 5.3 In order to successfully coordinate activities implemented by a variety of ministries, sectors and organisations, and commensurate with the development importance of the HIV/AIDS pandemic, the National AIDS Council will have very senior representation from the ministries and organisations involved. The Council will be chaired by the Minister of Health. 5.4 The National AIDS Councils functions will be: to monitor and coordinate the implementation of the National AIDS Policy, and Programmes that are developed within its framework.
12 11 to advocate for the active involvement of all ministries and sectors in HIV/AIDS prevention and care, with members ensuring the implementation of programmes in their own ministries and organisations to ensure that evaluation of the various components of national HIV/AIDS prevention and care programme is carried out to periodically review the National AIDS Policy, revise it as necessary in the light of emerging scientific and socio-economic information about HIV/AIDS and the pandemic to advise the Government on policy and strategic adjustments that need to be made in the national HIV/AIDS prevention and care response. 5.5 The Ministry of Health's AIDS/STD Unit will serve as the secretariat to the National AIDS Council, and will be appropriately strengthened to enable it to discharge this task. 6. ETHICAL AND LEGAL ASPECTS 6.1 HIV/AIDS, through its short- and long-term effects, has serious socio-economic and legal implications for individuals, and society. It is therefore necessary to address ethical and legal aspects of living with HIV/AIDS as a society in this policy. The guidelines contained in the national policy reflect the principles expressed in the Forty-first World Health Assembly Resolution WHA42.24 ("Avoidance. of discrimination in relation to HIV-infected people and people with AIDS ). The most important of these principles are: to enable persons with HIV/AIDS to lead productive lives of good quality for as long as possible, making their contribution towards the economic well- being and development of their families, communities and the country. to observe the public health rationale for the elimination of stigmatisation of, and discrimination against Persons with HIV/AIDS, so as to ensure that effective prevention and control measures are implemented with their cooperation to eliminate complacency and denial about the magnitude of the country's HIV/AIDS, problem at all levels, through the active and open involvement of Persons With HIV/AIDS in community education, prevention and care programmes. Where necessary, legislation will be developed to protect the rights of persons with HIV/AIDS, while ensuring that they fulfil their responsibility to protect others from infection.
13 HIV Testing Section 11 of the Public Health Act has provisions for dealing with deliberate attempts to infect others. Detailed guidelines regarding testing are contained in the Ministry of Health's Policy on HIV/AIDS (NACP Series No. 5). The following principles should be observed with regard to all testing for HIV: Except for the screening of donated blood and patients presenting with HIV-suggestive symptoms, routine testing for HIV/AIDS should not be carried out, and testing should not be done without the knowledge of the subject. Counselling should be offered and confidentiality maintained. Only individuals being screened for HIV during the conduct of anonymous, unlinked HIV serosurveys, as part of the national sentinel surveillance for the purpose of gathering epidemiological data to monitor the distribution and extent of HIV infection in various population subgroups will be tested without their knowledge. HIV testing will not be carried out against the will of individuals. Pre- and post-test counselling should accompany all testing in which the individual will be given test results. Referral for on-going supportive counselling should be offered as part of the post-test service. When private commercial organisations such as insurance companies require HIV testing, they should ensure that counselling accompanies such testing. Pre-employment HIV testing as part of the assessment of fitness to work is unnecesary, and should not be carried out. HIV testing should not be carried out as part of periodic medical examination of employees. Voluntary testing should be encouraged and provided, with appropriate counselling services 6.3 Confidentiality Detailed guidelines regarding the handling of information about the HIV status of individuals are contained the Ministry of Health Policy on HIV/AIDS Information about the HIV status of individuals (patients, clients, employees, etc.) should be treated confidentially, and not be divulged to others without the consent of the person concerned.
14 13 However, the principle of "shared confidentiality" should be applied, that is, those who need to know in order for appropriate health and social welfare care to be provided should be told. Family members should be involved from the outset in the management of Persons With HIV/AIDS with their consent. Health and social services providers should make all efforts to involve family members in the pre-test phase. There should be no obligation for the employee to inform the employer regarding his/her HIV/AIDS status. However, where the employee feels that sharing such information with a supervisor or employer would be helpful, health and social service providers should assist the employee Persons with HIV/AIDS should be made fully aware of their responsibility to prevent onward transmission to others. Their responsibility to sexual partners is paramount, and the Public Health Act provides for the prosecution of those who deliberately spread infections of public health importance. This principle and legislation should be applied for prevention of infections without resorting to victimisation of PWHIV/AIDS. 6.4 HIV/AIDS and Employment The workplace plays a central role in the lives of many young and middle-aged adults. The government as an employer, as well as private sector and parastatal organisations, will therefore have to manage staff affected by HIV/AIDS, and make decisions regarding recruitement, deployment, training, payment of terminal benefits, retirement due to ill-health, etc. The following principles will apply: Workers with HIV infection who are healthy will be treated the same as any other workers, with regard to training, promotion, etc. Being infected with HIV will not be a reason for an individual being declared unfit for employment, or for dismissal from employment. Workers with HIV-related illness and AIDS will be treated the same as any other worker with an illness. They should thus be retained in employment as long as they are medically fit to work. HIV-infected employees should have access to and receive standard social security and occupationally - related benefits Persons with HIV/AIDS in workplaces should be protected against stigmatisation and discrimination by colleagues, employers, unions and/or clients. Organisations should include aspects of this protection in workplace AIDS education and information programmes.
15 14 Employees should have access to information and educational programmes on HIV/AIDS and STD at the workplace, as well as to referral for appropriate counselling and medical care. Government should develop a prototype policy regarding HIV/AIDS and workers, consistent with the national policy. The policy should be communicated to all concerned, monitored for its implementation, evaluated for its effectiveness, and periodically reviewed in the light of emerging information about HIV/AIDS. 6.5 HIV/AIDS and Travellers There will be no restriction placed on travel by persons known, or suspected to have HIV/AIDS in Botswana. Foreigners entering the country will not be required to provide proof of freedom from infection. Foreigners known to have HIV/AIDS will not be restricted from entry for this reason. 7. RESOURCES FOR AIDS PREVENTION AND CARE PROGRAMMES AND AC- TIVITIES 7.1 HIV/AIDS prevention activities will be integrated into ongoing activities of ministries and organisations, in order to maximise the use of existing manpower, financial and other resources. 7.2 However, in order to develop the extensive and intensive programmes necessary to have significant impact on the HIV pandemic, additional resources will be needed. The government will, if necessary, increase funding for HIV/AIDS prevention and care activities to be implemented by various sectors including NGOs. This will include provision for additional key staff who will develop and coordinate the activities of various ministries and organisations. 7.3 Coordination of resources for HIV/AIDS prevention and care will be undertaken by the Ministry of Finance and Development Planning, in conjunciton with the National AIDS Council. 8. CONCLUSION HIV/AIDS is a dynamic and rapidly-changing field, about which new knowledge is constantly emerging. This policy will therefore be under regular review for its applicability and effectivess in the light of the most recent information, as well as responses from the community in Botswana. The National AIDS Council will ensure that changes are made following broad consultation with the nation.
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