HIV and Nutrition in Botswana
Firstly, apologies for the lack of pictures - I am posting this from remote North East Botswana with extremely limited Internet access!
Botswana is rightly proud of its record in dealing with HIV. In previous posts I've talked about the varying estimates of HIV prevalence in the country. If you take the more modest estimate of 20%, then there are around 300,000 Botswanans living with the virus. In 2001 the Government initiated the MASA programme to co-ordinate the ARV roll-out. At that time 3000 people were already on ARV therapy. By 2004 32 sites across the country were providing ARV therapy, and the plan is to increase this to almost 200 by 2010. Currently 90,000 people are on ARVs - about a third of those living with the virus. Here as in South Africa, ARV therapy is commenced when the CD4 count falls below 200. This compares with the US and Europe where treatment usually starts well before the CD4 falls to 300 (remember that a normal CD4 count is anything between 500 and 1200, and that at 200 or below the immune system becomes too weak to fight off opportunistic infections).
I visited two HIV clinics in Botswana - at Princess Marina Hospital in Gaborone, and Nyangabgwe Hospital in Francistown near the Zimbabwe border. Nyangabgwe is pronounced Nyan-ga-way by the way. Concentrating on the Nyangabgwe clinic, it is housed in a fairly small unit at the side of the hospital, but has managed to initiate 8000 people onto ARVs. The staff there told me about the kind of problems they come across on a daily basis.
Social problems are common. Often patients don't attend on the day of their appointment, perhaps coming along the next day instead. They say that they didn't have money to attend on the day of their appointment. Health services are free to citizens of Botswana. Others such as the increasing number of Zimbabwean refugees have to pay. However each time a patient makes a visit to see the doctor or dietitian they must may a 10 pula admin fee (about 80 pence or US$1.50), and a bus to and from the hospital may cost up to 50 pula return for each person coming along. You can see that for a mum and 2 kids the cost can become significant - 160 pula is a week's wages for some.
I was told that many children are failing ARV therapy, often trying the third and final line of therapy available in Botswana. The key to preventing viral resistance occurring in the first place is adherence support. At Guy's and St. Thomas' Hospital where I work in London all members of the health team check on how the patient is coping with their antiretrovirals. The doctor, nurse, pharmacist and dietitian all have a role to play, and for those patients experiencing difficulties there is a specialist adherence nurse. The dietitian has particular skills in looking at daily patterns. When asking about times of meals and activities, the dietitian is best placed to look for a lack of routine, an indicator of potential problems with taking ARVs at the same time each day, day in and day out.
In the ARV clinics in Botswana there are lay counsellors who advise patients on the importance of adherence prior to starting on the medicines, but other than this little support apart from brief questioning from the medical team.
Dietetic support at the ARV clinics is minimal. As I pointed out in a previous post, there are only 16 dietitians for the whole Botswana Health Service. In South Africa by comparison, the aim is for every ARV clinic to have a dedicated dietitian. Nurses and doctors in Botswana say that they see little malnutrition, but the dietitians say that it is often being missed. In my experience patients with malnutrition at the point of initiation on ARVs have problems with adherence.
I had two very productive meetings with the Dept of Health and the HIV training programme (KITSO) where we discussed HIV and nutrition. They agreed that now the roll-out of ARVs had been successful, support and adherence should be a priority. We discussed the following:
Botswana is rightly proud of its record in dealing with HIV. In previous posts I've talked about the varying estimates of HIV prevalence in the country. If you take the more modest estimate of 20%, then there are around 300,000 Botswanans living with the virus. In 2001 the Government initiated the MASA programme to co-ordinate the ARV roll-out. At that time 3000 people were already on ARV therapy. By 2004 32 sites across the country were providing ARV therapy, and the plan is to increase this to almost 200 by 2010. Currently 90,000 people are on ARVs - about a third of those living with the virus. Here as in South Africa, ARV therapy is commenced when the CD4 count falls below 200. This compares with the US and Europe where treatment usually starts well before the CD4 falls to 300 (remember that a normal CD4 count is anything between 500 and 1200, and that at 200 or below the immune system becomes too weak to fight off opportunistic infections).
I visited two HIV clinics in Botswana - at Princess Marina Hospital in Gaborone, and Nyangabgwe Hospital in Francistown near the Zimbabwe border. Nyangabgwe is pronounced Nyan-ga-way by the way. Concentrating on the Nyangabgwe clinic, it is housed in a fairly small unit at the side of the hospital, but has managed to initiate 8000 people onto ARVs. The staff there told me about the kind of problems they come across on a daily basis.
Social problems are common. Often patients don't attend on the day of their appointment, perhaps coming along the next day instead. They say that they didn't have money to attend on the day of their appointment. Health services are free to citizens of Botswana. Others such as the increasing number of Zimbabwean refugees have to pay. However each time a patient makes a visit to see the doctor or dietitian they must may a 10 pula admin fee (about 80 pence or US$1.50), and a bus to and from the hospital may cost up to 50 pula return for each person coming along. You can see that for a mum and 2 kids the cost can become significant - 160 pula is a week's wages for some.
I was told that many children are failing ARV therapy, often trying the third and final line of therapy available in Botswana. The key to preventing viral resistance occurring in the first place is adherence support. At Guy's and St. Thomas' Hospital where I work in London all members of the health team check on how the patient is coping with their antiretrovirals. The doctor, nurse, pharmacist and dietitian all have a role to play, and for those patients experiencing difficulties there is a specialist adherence nurse. The dietitian has particular skills in looking at daily patterns. When asking about times of meals and activities, the dietitian is best placed to look for a lack of routine, an indicator of potential problems with taking ARVs at the same time each day, day in and day out.
In the ARV clinics in Botswana there are lay counsellors who advise patients on the importance of adherence prior to starting on the medicines, but other than this little support apart from brief questioning from the medical team.
Dietetic support at the ARV clinics is minimal. As I pointed out in a previous post, there are only 16 dietitians for the whole Botswana Health Service. In South Africa by comparison, the aim is for every ARV clinic to have a dedicated dietitian. Nurses and doctors in Botswana say that they see little malnutrition, but the dietitians say that it is often being missed. In my experience patients with malnutrition at the point of initiation on ARVs have problems with adherence.
I had two very productive meetings with the Dept of Health and the HIV training programme (KITSO) where we discussed HIV and nutrition. They agreed that now the roll-out of ARVs had been successful, support and adherence should be a priority. We discussed the following:
- How to increase the number of dietitians in Botswana
- Development of dietetic assistants and nutrition nurses or nutrition health care workers
- Development of a nutrition risk screening tool
- Incorporation of training around nutrition and HIV into the national programme
posted by Alastair at
Friday, September 21, 2007
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