Botswana

1.        General and Epidemiological Data

1.1.    General data on Botswana

1.1.1.     Botswana – Country Profile

Botswana is a landlocked country in Southern Africa bounded by Namibia, Angola, Zambia, Zimbabwe and South Africa. It is roughly the size of France or Kenya at 581 730 sq. km.

It is a country of natural beauty with deserts in the Kalahari, swamplands in the Okovango Basin and salt pans in the Makgadikgadi Pans and 17% of the country is protected wild life area.

The capital is Gaborone where an estimated 180 000 people live and more than 65 000 live in Francistown.

The population (2001) is estimated to be 1.6 million, approximately 3 persons per square km, and is one of the lowest population densities in Africa. This figure can be misleading however, since 80% of the population live in the eastern third of the country resulting in highly localised population densities. This distribution pattern is due to two factors, namely that the Kalahari Desert to the west is inhospitable and has very limited surface water. Secondly, the historical political organisation of the Tswana was such that satellite villages were never built too far from the central villages, in order to keep the community close.

Botswana has one of the highest population growth rates in Africa with 3.5% per annum. This represents about 5.8 live births per female of childbearing age. With the impact of HIV/AIDS, the population growth rate is expected to decline to 2.6% in the period 1995-2015.

1.1.2.     People

Batswana

Over 50% of the population is made up of the Tswana (Batswana), a people of Bantu heritage. Botswana means "Land of the Batswana." There are 8 major Tswana tribes, each of which oCCupies its own separate territory with its own traditional chiefs. Each tribe maintains communal ownership over its land. The Tswana have a rich tradition of folklore, music and dancing and their lives are still strongly influenced by tribal institutions.

Baka langa

The Bakalanga mainly live in the Francistown area and are the second-largest group in Botswana. As with many other tribes, international borders have split them up, with a large portion of them living in Zimbabwe.

Bakhalagari, Bayei, Hambukushu, Basubiya are tribes scattered in different areas of Botswana such as the Gembok National Park area and the Chobe.

Ovaherero

The Herero fled from the Germans in Namibia in 1904/05 when they were waging their colonial wars and settled in the Delta. Today many of them are found in Maun. The women of this tribe can be recognised on the streets of Maun by their beautiful, long colourful dresses.

San and Khoi

The Khoi (Hottentot) and the San (Bushmen) have been in Southern Africa some 25000 years. They live mainly in Namibia and Botswana and about 52000-55000 live in Botswana. The San are the only inhabitants who are adapted to survive in the harsh Kalahari Desert. Unfortunately their culture and knowledge of the bush is dwindling at a rapid pace.

1.1.3.     Government

Since Independence from Britain in 1966, Botswana has proven to be something of a model in Africa – a stable, democratic government, sound economic policies and a healthy economic base largely supported by diamond revenues.

Botswana is a multiparty democracy. Under the Botswana Constitution, legislative power is vested in the Parliament, which comprises the president as ex-officio member and a unicameral National Assembly. Within the Assembly is the speaker, the Attorney General (non-voting), 40 elected members and four members specially elected by the Assembly. Elections are held every 5 years. A 15-member House of Chiefs advises on tribal matters.

1.1.4.     Economy

This vast, thinly populated country is one of Africa's few economic suCCess stories. In 1966 when Botswana became independent, it was considered one of the 20 poorest countries in the world. In 1967 the discovery of diamonds changed the picture dramatically and Botswana became the largest producer of diamonds by value in the world. Thus Botswana has been able to aCCumulate huge foreign exchange reserves which, in per capita terms, is one of the highest in the world.

The mines are jointly owned by the Botswana Government and by De Beers Mining Company, the Debswana Diamond Company.

Apart from its mineral wealth, Botswana's economic suCCess can be ascribed to the beef industry, vehicle and textile exports and above all, good governance.

It has shown a remarkable economic growth of 7%. Gross Domestic Product (GDP) currently stands at over US$3 000 per capita and provision of basic social services is comprehensive.

1.1.5.     Profile of Human Development

The economy of Botswana had some inherent structural defects -a narrow economic base (largely diamonds); a small, poor and largely unskilled population; and under developed markets amongst others. A deliberate strong developmental role for the state was necessary in order to make progress in Botswana's human development. The strategy was simple: mineral revenue would be used to develop infrastructure, diversify the economy and develop essential human capabilities.

The main thrusts of this strategy were:

· Education and health as long term responses to poverty and unemployment

· Employment creation based on generous government subsidy support. Examples of incentive programmes include: the Financial Assistance Policy (FAP), the Micro Credit, and Credit Guarantee Schemes

· Aggressive pursuit of foreign direct investment, based on credible and enforceable property rights, low taxation, liberal regulatory business framework and FAP

· Rural development with extension of basic services to rural areas and incentives for agriculture and business

· Social safety nets for economically vulnerable groups: elderly, disabled, destitute and orphans

(Ref: UNDP/GOB Botswana Human Development Report)

1.1.6.     Health

There has been sustained improvement across most health indicators in Botswana over the last two decades.

ACCording to UNICEF's State of the World's Children Report 2000:

· Of the total population of 1.6 million, 50% are under 18 years and 15.4% under 5 years of age.

· Under 5 mortality rates fell from 170 per thousand live births in 1960 to 48 per thousand in 1988 and, with the impact of AIDS, have stayed at that level for the past 10 years.

· Infant mortality rates fell from 170 to 38 per thousand live births between 1960 and 1998 and have also stayed at that level.

· 90% of the population have aCCess to safe water (100% urban: 88% rural).

· 55% have aCCess to adequate sanitation (91% urban: 41% rural).

· Literacy rate is 73%

ACCording to SADC Regional Human Development Report 1998:

· Maternal mortality at 220 maternal deaths per 100 000 births is the second lowest in the region.

· Life expectancy increased by 19 years between 1960 and 1993. However, due to the impact of AIDS, life expectancy decreased from 59.8 years in 1990, to 51.7 years by 1995. It is expected to decrease to 33 years by 2010. Botswana's annual population growth rate is projected to decline from 3,3% in the period 1970 – 95 to 2,1% in the period 1995 – 2015.

· In 1995 Botswana had the highest cases of tuberculosis in SADC at 390 per 100 000 people

TB remains the biggest killer in the country. There is a strong TB programme. Contact investigation is poor but there are moves to prioritise contact tracing for the most infectious forms of TB. Recently Government has embarked on a TB Preventative therapy programme with the Centre for Disease Control (CDC). The programme, called the "Isoniazide Preventative Therapy" (IPT) programme, has been started in 3 districts and aims to go nationally. Anyone testing HIV positive and found on screening to be free of active TB is given six months of preventative TB therapy. This costs US $4.00 per patient and has been found to reduce the risk of TB by 60%.

Provision of health services is free. There are no obvious drug shortages except for mismanagement. Government has a fully funded home based care programme. The Government is planning on widespread aCCess to anti retroviral therapy for HIV positive patients.

1.1.7.     Poverty and Vulnerability

Poverty remains a major problem. The income gap between the poorest and the richest members of society is very wide. The 1991 census showed that 47% of households are female headed and 52% of these are in the rural areas. Unemployment and poverty is to be found in both. There is a large population of mobile workers caused by transfers and camping out employees. Almost one in two Batswanas still live in poverty.

Rapid growth in formal sector employment has been one of the main factors that explains improvement in living standards in Botswana. However, disparities in aCCess to formal sector employment provide much of the explanation for disparities in income levels.

The unemployment rate is 21% of the population.

Efforts to eradicate poverty and reduce inequalities would need to include greater social mobilization amongst the poor to participate in state-led economic empowerment programmes. These involve micro-financing schemes, small-scale urban agricultural projects, improved food security, and self-employment initiatives.

1.2.    Epidemiological Data

1.2.1.     HIV/AIDS Epidemic in Botswana

"We are threatened with extinction. People are dying in chilling numbers. It is a crisis of first magnitude."

Festus Mogae. President of the Republic of Botswana.

The first reported case of AIDS was in 1985. Botswana now has the highest record of HIV prevalence rates in the world. The national median HIV prevalence, in 15 – 49 years old, has increased from 18% in 1992 to 36% in 2000. In 2001, the median prevalence rates confirm the trend of a growing epidemic and appear to be as high as 38.5%.

Approximately one baby is infected with HIV every hour.

An estimated 290 000 people are HIV infected and to date 24 000 AIDS deaths have oCCurred.

Even with significant changes in behaviour, it is estimated that around 540 000 Batswanas will die in the next 20 years. That is equivalent to 1/3 of the country's current population .

1.2.2.     Sentinel Surveillance

Sentinel surveillance has been carried out, since 1992, in women attending antenatal clinics and in men presenting with sexually transmitted infections. The sero-survey of eight sites in 1999 revealed alarming statistics whereby the highest prevalence rate in Chobe reached 50.83% whilst Francistown recorded 43%. In Gaborone (the capital) HIV prevalence is 44% in 15-49 years old (NACP Report 2000). The high prevalence rates in ANC and STD clinics in Francistown and Gaborone is disturbing because of the economic status of the sites.

There has been a frightening increase in the HIV prevalence in the 15 -19 year olds whereby it has increased from 16.4% in 1992 to 26.7% in 2000. This reflects the most recent infections as the age group represents the age at which sexual activity has just begun. There has been no decline in this age group at any time.

1.2.3.     Contr ibutory Factors to the Spread of HIV/AIDS

- Mobile Population:

With good transport and road infrastructure, and disposable income, the population is mobile. There is considerable migration for employment as well. Isolation from traditional culture and social networks frequently results in risky behaviour.

- Cultural Aspect

Most Batswanas speak of having more than one home, usually four homes: the home they come from, the city or town in which they work, the home near where they plough and grow their crops and a home at the place where they ranch their cattle. This translates into a lot of mobility by the people and good communications facilitate that. Chance of multiple sex partners are very high.

- Poverty and Inequality

47% of the population live below the poverty line despite extensive development in the country. Poverty influences choices people make including behaviour that increases risk of HIV infection: alcohol abuse, multiple sex partners and sex for money.

- Sexually Transmitted Infections (STI)

The presence of a concurrent STI/STD greatly facilitates transmission of HIV. The incidence is high. Proper and timely administered treatment for STI reduces risk of HIV infection. Correct use of condoms is even more effective. Even though health services are free, the concern is whether or not these are "youth friendly" and whether judgmental attitudes toward sexually active youth create a barrier to youth presenting for early treatment.

- Mother to Child Transmission

Approximately 7 – 9 000 children are infected yearly through this route.

- Intergenerational Sex

Women are infected with HIV at much younger ages compared to men. HIV is transmitted from older men to young girls who in turn infect boys their own age.

- Sexual Abuse

There is belief that sex with a virgin (young girl) will cleanse an infected man of his HIV/AIDS.

It is widely discussed that young girls are frequently taken to remote cattle posts where men abuse them in the absence of witnesses.

Employment opportunities and advancement appears to be frequently linked with demand for sexual favours.

ACCording to UNAIDS Global Report on HIV/AIDS 2000 a review of police and court records show a steady rise in reported cases of rape. Two-fifths of all cases reaching the courts involve children under the age of 16.

It is suggested that sexual abuse of young girls exposes them to risks of HIV/AIDS and also may lead to them taking sexual risks in adolescence, perhaps in part because abused children have lowered self-esteem and find it harder to assert themselves in sexual negotiation in later life.

- Gender Inequality

With unequal power relationships, women have difficulty negotiating for no or safer sex. There is also unequal employment and aCCess to wealth, and unfair division of labour. Violence (battery and rape) oCCurs.

- Sex Education: Cultural Taboos

Sexual education taboos with parents and the lack of openness on subjects of reproductive health has limited the forum at which youth can readily aCCess aCCurate information in order to make informed personal choices. Textbook biological knowledge and limited media information does not necessarily translate into responsible behaviour.

- Silence and Denial

This is rampant.

- Lack of Anti-Retro-Viral Therapy (ARV)

With the lack of aCCess to ARV therapy, motivation for voluntary counselling and testing has been limited. Awareness of sero-status has been proven to reduce risky behavoiur.

1.2.4.     Impact of HIV/AIDS in Botswana

As a consequence of HIV/AIDS, life expectancy is expected to decrease to 42 years (NACP) or even as low as 33 years (UNDP) by 2010.

Infant mortality will increase from 41 to 65 per 1000. Currently one in every eight children born is HIV positive. An estimated 64% of deaths in children under 5 years are thought to be caused by AIDS through mother to child transmission.

Macro-economic Impact

There will be an anticipated 33% less economic growth by 2020, than there would be without HIV/AIDS, through the loss of young adults in their most productive years. The current estimate of 65 000 orphans will increase to 240 000 by 2020 with an associated impact on the economy.

The Government budget is likely to be reduced by over 20% through increased expenditure with reduced revenue.

Households Impact

Progressive loss of income, increased health care expenditure and reduced agricultural production will lead to an overall increased burden on the extended family. This same extended family will be responsible for the increasing burden of orphan care as the epidemic unfolds.

There is likely to be a greater drift to urbanization and it is estimated that by 2021 60% of Batswanas will live in urban areas (compare 40% today). This will result in a significant decline in the rural population which will progressively consist of the elderly and young AIDS orphans. The increased urban population will increase the water stress of these areas as well.

2.        National HIV/AIDS Infection Control Programme

2.1.    The National Response of Botswana

Unlike many other countries, Botswana has "National Ownership" of the national response programme. The Government funds more than 80% of the cost of the national HIV/AIDS prevention and control activities in Botswana.

1985              First identified case of AIDS

1986              Blood screening programme introduced under the Epidemiological Unit of Ministry of Health

1987-1989      Interim Short Term Plan (STP) introduced to focus on raising public awareness about HIV/AIDS, training health workers in clinical management of HIV/AIDS

Phase I

1989 –1997  First 5 year Medium Term Plan (MTP1)

§ strengthen surveillance activities

§ prevent sexual transmission

§ prevent transmission through blood product

§ prevent peri-natal transmission

§ set up systems for monitoring and evaluation

Phase II

1992    AIDS/Sexually Transmitted Diseases Unit (ASU) established to coordinate NACP

ASU operates through 7 sub-units focusing on:

1.    Counselling and Home Based Care

2.    Information Education Communication (IEC)

3.    Surveillance and Research

4.    Sexually Transmitted Diseases (STD)

5.    Non Government Organisations (NGO)

6.    Clinical Management

7.    Sector Support

1992    Community Home Based Care (CHBC) concept introduced and piloted in 1995

1992     National AIDS Council established and National AIDS Policy drawn up

1993     MTP II process began to involve more stakeholders, NGOs and private firms to become a multi-sector approach

1992-2000    Goals:

§ To reduce HIV infection and transmission

§ To reduce impact of HIV/AIDS at all levels of society; social economic and culturally

29 October 2000 , President Mogae launched a comprehensive social mobilization campaign on HIV/AIDS awareness.

A fund has been established to support NGOs and CBOs working in HIV/AIDS and an NGO coordinator was appointed to the AIDS/STD Unit.

The national strategic plan builds on the national policy on HIV/AIDS with concerted action from all sectors led by the Ministry of Health and the National Coordinating Agency (NACA).

Health and Local Government Ministries, Social and Community Development Department, are responsible for the care and welfare of orphans and AIDS patients. They provide food rations for orphans and AIDS patients on home based care. The Ministry of Health provides AIDS patients, on HBC, with gloves, bed-pans, disposable nappies, detergents and more.

The multi-sector response coordinated by the NAC and chaired by the President features the following responsibilities:

· Office of the President provides political leadership for the national response and ensures mobilization of all sectors, including policy makers and private resource sources

· Department of Information and Broadcasting actively disseminates HIV/AIDS information in collaboration with the Ministry of Health, NGOs and CBOs (Community Based Organisations).

· Director of Public Service Management targets policy for public service and workplace programmes

· Ministry of Health is required to 'lead the development and refinement of strategies for prevention and care, involving other Government agencies, NGOs and the private sector' and 'provide technical support to other ministries and sectors as they develop and implement their own HIV/AIDS prevention and care activities.'

· Ministry of Education is required to incorporate AIDS and STD education into all educational institutions and involve parents

· Ministry of Labour, Home Affairs and Social Welfare ensures People Living With AIDS (PLWA) rights are protected and implement prevention programmes

· Ministry of Finance and Developing Planning mobilises resources

· Minstry of Local Government is responsible for eligibility assessments for destitution support for PLWA and orphans

· Private firms are expected to develop HIV/AIDS staff programmes, including training and mobilizing appropriate resources

· NGOs and CBOs are responsible for advocacy and social mobilisation, for prevention and care and home based care programmes.

(UNDP Report)

In order to decentralise this multi-sector response, District and Sub District Multi-Sector AIDS committees ( DMSAC ) have been set up to local Government level.

District Development Committees (DDCs ) support the DMSACs by coordinating both Government and NGO activities at community level. This level represents an area of confusion in terms of responsibilities, authority and aCCountability.

2.2.    Partnerships

Several partnerships operate between the Republic of Botswana and International Organisations with the overall goal to strengthen the MTP II.

These partnerships include:

- African Comprehensive HIV/AIDS Partnerships in Botswana (ACHAP)

A novel partnership launched by Botswana, the Gates Foundation and Merck & Co. Inc. $100 million over a five year period is made available with free provision of MTCT. It seeks to aCCelerate aCCess to, and increase the use of, appropriate high quality interventions for the prevention, treatment and care of HIV-related illnesses. It is designed to demonstrate that a comprehensive partnership approach to improving the health care infrastructure can be implemented and sustained.

- Global AIDS Programme(GAP) through the CDC as part of Life Initiative

Funding for this programme is $8 million per year and it concentrates on four programmes:

Voluntary Counselling and Testing (VCT)

Isoniazide Preventive Therapy (IPT) for TB

Supporting prevention of Mother to Child Transmission (MTCT)

Supporting IEC programmes (radio drama)

It also involves the provision of an epidemiologist to NACA and building the laboratory capacity together with ACHAP.

- Support by UN Agencies

WHO

Support for surveillance, research, monitoring and evaluation

UNICEF

Provides support to NACA in drafting a national HIV/AIDS Strategy on IEC and support for IEC in mass media

UNDP

Offers sector support and the South-South initiative in building teacher capacity (funded by ACHAP)

UNFPA

Supports an alliance with Youth of Botswana through UNFPA ($1.8 million funded by Ted Turner Foundation for urban youth and $7.9 million funded by the Gates Foundation)

- Botswana-Harvard Partnership for HIV Research and Education

This partnership focuses on research on HIV-IC (funded by NIH); a Botswana specific vaCCine; clinical trials in MTCT; resistance in adults; education and training of Health Care Workers and provides small grants to NGO's on IEC.

- Secure the Future (BMS with Baylor College of Medicine)

This paediatric treatment and resistance study seeks to establish a Centre of Excellence for paediatric research and care at the Princess Marina Hospital in Gaborone. It also provides small grants to NGO's.

- Department for International Development (DFID)

$7.5 million have been allocated for four countries – Botswana, Namibia, Swaziland and Lesotho-but programmes have yet to be identified.

Anti-Retro-Viral medication affordable?

The cost of HIV/AIDS medication is falling rapidly. Reductions in the price of these medications have now made their use economically feasible in Botswana. A widespread campaign promoting the use of HIV/AIDS medication would cost between 1.4% and 2.3% of government budget by 2011. This corresponds to between 9-16% of government surplus.

2.3.    NGO Response / Private Sector Response

The private sector has shown an increasing willingness to be involved in the fight against the disease. Numerous excellent initiatives are currently operational and it is hoped that many other businesses will be similarly challenged to respond. Of particular note is the following:

Debswana Diamond Company

In 1991 Debswana started an HIV/AIDS campaign amongst employees and appointed full time AIDS coordinators for the dissemination of information, counselling and advice. It was stated that:

"It is company policy to protect the health and safety of employees and it makes good business sense."

The HIV/AIDS Management Policy is based on the company's Health and Safety regulations and serves as education and prevention and, more importantly, to articulate Debswana's position on employees who are living with the virus. Equal rights are afforded to all employees, and people living with HIV/AIDS have the same rights and opportunities as those

with other life threatening illnesses. Employees are encouraged to go for voluntary counselling and testing.

An internal audit recently revealed that 59% of company deaths and 75% of all ill health and retirements were due to HIV/AIDS and the seroprevalence of the company was 28.8%. The increasing demand for health services coupled with the loss of production and the decline in staff morale prompted a new response and the development of a new HIV/AIDS strategy which has enhanced IEC and is youth focused. This new initiative has now included, as company policy, the provision of anti-retroviral therapy for all infected employees

A committed response towards addressing HIV/AIDS within the private sector has a ripple effect on other organisations and this initiative has prompted other companies, even in neighbouring countries, to also reexamine company policy toward their own employees.

3.        Position and Involvement of the Churches in Addressing HIV/AIDS

In 1996 President Masire of Botswana publicly appealed to the Churches of Botswana to help in the national fight against AIDS. Since most Batswana identify themselves with a church, it would appear that the various churches represent the most persuasive, grassroots network in the country.

Various efforts have since arisen, both within the Christian community and outside, to combat AIDS.

3.1.    Churches in Botswana

Approximately 50% of the population are Christian. The Churches are well represented throughout Botswana and are the most noted community structure, particularly in the absence of other structures. There are 216 registered churches and faith-based organisations in the country.

The Botswana Christian Council stated that every government ministry holds a prayer meeting once a week and they cited in particular the ministries of telecommunication, power, water and parastatals who pray regularly for orphans in the churches.

Principally the churches fall into five main categories:

1. The United Congregational Church in Southern Africa

2. Roman Catholics

3. Lutheran / Anglican

4. Southern African Alliance of Reformed Churches

5. Independent Churches

3.2.    Perceptions of HIV/AIDS by the Churches

"HIV/AIDS is claiming lives daily and statistics are showing. To a large extent the church is putting up a great silent fight."

D. Modiega Botswana Christian Council

"We are faced with a big problem of denial in the church; as a result our clergy are not well equipped to deal with the affected. The sermons are not comforting and the counselling is below par."

B.Moleko: Botswana Christian Council

" The Church still has to learn to listen to the afflicted and be comforter rather than condemn." B Moleko:

Botswana Christian Council

The denial and stigma is mainly culturally based. To openly talk about sex within the life of the church is a taboo. Churches need a mechanism to overcome this taboo. The government is looking to the churches to become partners but the situation is stalemated over culture and tradition.

3.3.    Involvement of the Churches in HIV/AIDS Awareness for Clergy and Congregations and Laity

Congregations and laity

"Now is the time to be courageous and take steps in re-thinking our theology. In view of the magnitude of the problem, is it not time that we removed controversies in health? The use of condoms, for instance, which the Church is refusing to embrace, even if it is not completely safe, is a preventative and is the only alternative in situations where people are not sure of their status. Messages in the media and movies are going one direction. People are not hearing the countering good messages of prolonged, safe good living and we shy away from this responsibility. The battle is greater because we have to fight attitudes."

David Modiega: Botswana Christian Council

3.3.1.     Botswana Council of Churc hes (BCC)

The Botswana Christian Council is an ecumenical movement designed to bring about church unity and cooperation among different churches in Botswana. Prior to its formation, churches in Botswana acted independently because of their doctrinal, historical, cultural, political and philosophical differences. These differences were aggrevated with the emergence and proliferation of African Independent Churches which led to further divisions in the Church. The first Northern Bechuanaland Christian Council was established in1965. The primary objective of the council was to respond collectively to crisis such as droughts, famine and outbreaks of disease. It was basically an inter-church relief programme and it was in all aspects, the predecessor of the BCC as it is known today. The BCC was inaugurated in 1966.

All main line churches in Botswana are represented in the Council. It has links with the Evangelical Fellowship of Botswana as well. The BCC is an affiliate member of the All Africa Conference of Churches. It is also part of EDICESSA, Ecumenical Documentation and Information Centre for East and Southern Africa, and FOCCESA, Fellowship of Christian Councils in East and Southern Africa.

The BCC represent the churches of Botswana on NACA as well as the National Poverty Alleviation Programme.

The Council operates through several departments and units such as a Communications Unit, Urban Industrial Mission for education and skills training, and Social Concerns Department, responsible for issues on democracy, justice and civic education. It has a Youth Council which works on behaviour change through church youth clubs. The Botswana Youth Council funds youth brigades, youth initiatives and soCCer clubs.

BCC is also involved in the "know your mother" initiative

The BCC has the foundations and the historical background to coordinate denominational activities and disseminate relevant information between the churches. However, in discussions with numerous denominations in Botswana, it was revealed that not many view the BCC as relevant to the initiatives that have been started in their churches and have limited meaningful debate and involvement with the BCC. Several are seeking their own representation on NACA, independent of the BCC.

Faced with a 'national emergency' as a consequence of HIV/AIDS, perhaps a refocus may be necessary.

3.3.2. The United Congregational Church in Southern Africa – Synod of Botswana

The UCCSA in Botswana constitutes a synod. It is divided into two regions each with a regional council. Regions consist of local congregations which are supposed to be self-regulating. There are 59 congregations established throughout the country.

The church is involved in theological training in Kgolano College and the Department of Theology and Religious Studies at the University of Botswana.

The church also has strong Sunday Schools and is involved in the work of the SOS Children's orphanage in Tlokweng. It operates a hostel in Francistown to enable blind children of primary age to attend school. The church has a full time youth officer who runs youth programmes for the church but also part of the National Youth Council in the Ministry of Home Affairs.

The Synod of Botswana began its AIDS initiative in January 2000. Two full time AIDS coordinators help churches develop a response to HIV/AIDS. In that capacity they have conducted workshops across the country with pastors, church leaders, every constituency group and many congregations. The workshops offer basic information about the disease as well as training in pastoral care skills, home based care, and responding to orphans. The aim is to help congregations initiate programmes in their individual communities that will meet identified needs in the community. The coordinators then serve as facilitators to help those programmes get off the ground.

Currently they have a number of churches participating in home based care programmes and one church has begun a programme for orphans in the community. These churches are recognised as "AIDS Active Congregations." It is hoped that many more will follow.

3.3.3.     Roman Catholics

The Catholic Church in Botswana constitutes a suffragan diocese of the Archdiocese of Bloemfontein in South Africa. The Diocese of Gaborone is a member of the Southern Africa Bishops Conference whose headquarters are in Pretoria. The diocese is divided into 22 districts. There are 28 congregations.

The Catholic Church is involved in many activities in education, health and other socio-economic developments in the country for the development of the whole man. Some of the activities include the following:

· Theological training: Priests are trained in Zimbabwe. However in Botswana the Church has the Kanamo Centre in Mahalapye which is used for educational activities both by the Catholics and other churches as well as government in its training programmes.

· Child Welfare: the church runs a number of creches

· Relief programmes: most missions have small relief programmes for the needy and destitute

· Formal education: the church has 2 secondary schools, 9 primary schools, 1 adult education centre, a study group and a Commercial School.

· Health: The church has 2 clinics in Kgale and Ramotswa.

· Socio-economic projects: the church has a project coordinator who initiates local projects like sewing centres to create self-reliance. Women's groups are also involved in this area.

· Youth work: the church has 2 major youth groups known as CHIRO and SLG

· The Roman Catholics, represented by the Tirisanyo Catholic Commission, are responsible for an effective orphan programme in Mogoditshane. In 1992, the Tirisanyo Catholic Commission developed home based care at Mogoditshane village in the Kweneng District as a response to the HIV/AIDS epidemic in the country. The ensuing plight of orphans also necessitated a response and in 1999 the orphan programme was initiated. It is hoped that it will serve as a replicable model of intervention involving government, private sector, NGOs and community. Services are provided in the form of registration, feeding and a day care centre for those below primary school age. The programme is being extended to incorporate counselling, support groups and recreational facilities to encourage socialisation.

3.3.4.     Lutherans/Anglicans

Evangelical Lutheran Church in Botswana (ELCB)

In 1975 the Evangelical Lutheran Church of Botswana was formed which included the Lutheran Church of Botswana as one of its dioceses. In 1978 three Lutheran groups-the Hermannsburg Missionary Society, the Berlin Missionary Society and the Rhenish Missionary Society forged a union and declared their independence from the mother church the ELCSA

The ELCB has a congregation of 16-18 000 with 30 pastors, 30 congregations and outstations. They are responsible for the Woodpecker Seminary where 6 week courses on counselling in HIV/AIDS are held for pastors and laity.

Up to 3 times a year, a Sunday service is set aside to talk to the congregation about AIDS.

Confirmation classes include a lesson on AIDS. Where peer educators are deemed desirable for a congregation, they are sent for training with the Botswana Youth Council.

Home based care was seen as a priority area such as the Home Based Care Project in Sehitwa. The issue of orphans was not seen as a priority.

Lutherans do not hold premarital counselling courses at which the issues of HIV/AIDS could be discussed frankly with couples. They recognise the need for this service by the church.

ELCB operates a "Rehabilitation Centre" in Maun. In Francistown, together with the Finnish Evangelical Mission, they run programmes for out of school youth and adult non-formal education. This diaconal work is termed a "Suburban Mission."

Though some congregations are attempting to tackle the effects of AIDS, particularly in home based care, in general ELCB leaders felt that the church has not started to seriously address the issues of HIV/AIDS and has no formal policy on HIV/AIDS. The exception is in Maun where there is an organisation called "Pastors Against AIDS," a subsidiary committee at District Level of the "Botswana Christian AIDS Intervention Programme in Maun." "Pastors Against AIDS" have been active since 1996, involved in AIDS awareness and prevention campaigns. This was purely initiated and supported by the local Christian community through pastoral leadership of which ELCB is a member.

The Lutherans and BOCAIP started the counselling centre in Maun, as well as a day-care centre for orphans. Under this initiative, all seminarians, congregation deacons and deaconesses and pastors attend a six-week counselling course on HIV/AIDS. Lay people may aCCess this training programme as well.

Lutheran Church of Southern Africa (LCSA)

LCSA has 10 parishes with 41 congregations countrywide. It is committed to serving its communities in the areas of youth work, health, education and socioeconomic development.

Together with the ELCB, LCSA is involved in the running of the Bamalete Lutheran Hospital in Ramotswa and Thuso Centre in Maun.

At the Bamalete Lutheran Hospital is the "Ramotswa Hospice at Home." This is a home based care programme which is also involved in community education, with volunteer recruitment, and provides counselling on HIV/AIDS to both clients and caregivers.

Anglican Church

The Anglican Church has 17 parishes. Youth work is one of the top priorities of the church.

It is a founder member of the Botswana Christian Council and Kgolagano College, which is a theological training college by extension.

Following an initial programme of community education and mobilisation on HIV/AIDS, the Anglican Church founded the Holy Cross Hospice in 1994 to address the needs of the terminally ill patients by providing and supporting home based care. It now provides care and support for over 100 patients and conducts training for home based care volunteers.

3.3.5.     Southern African Alliance of Reformed Churches (SAARC)

SAARC is a fellowship of 19 Congregational, Presbyterian and Reformed Churches which are members of the World Alliance of Reformed Churches. At the end of 2000 SAARC prioritised HIV/AIDS as the top item on the agenda. HIV/AIDS was described as a "faith issue." The Reformed tradition was to be the guiding principle in all their responses and ministries in the HIV/AIDS area. It was established that there was need for a faith statement in response to HIV/AIDS and that pastors and other care givers needed to be equipped with spiritual resources. It was decided to focus its actions at country level in close cooperation with the local churches. UCCSA, DRCB and ELCB are now cooperating.

3.3.6.     Botswana Christian AIDS Intervention (BOCAIP)

In 1996 the Christian churches initiated an ecumenical HIV/AIDS intervention under the umbrella of one programme which was called the Botswana Christian AIDS Intervention Programme (BOCAIP). The churches involved included ELCB (Maun), Catholic, Anglican, most of the Pentecostals, Independent, Open Baptist, African and the Ministers' fraternal. In order to offer competent and quality service on both preventative and care fronts in HIV/AIDS it was felt that comprehensive training was a necessary prerequisite. The object BOCAIP was to develop a countrywide network of church based Christian counsellors, equipped with skills and knowledge for prevention, counselling the infected and the affected, and supporting families and communities.

It was felt that the church commands an unrivalled audience in the country and, with a widely based volunteer counselling network, the church institutions-together with other institutions-could positively affect the entire AIDS movement in the country.

It has developed into a national programme operating in 5 centres:

· Tshepong Counselling Network in Gaborone

· Tsholofelo Counselling Centre in Lobatse

· Emmanual Counselling Centre in Ramotswa

· Kaletso Counselling Centre in Molepolole

· Maun COunselling Centre in Maun

· The programmes include:

· Counselling and home visitation

· Material assistance

· Community outreach

· Support groups for PLWA

· Orphan care

· Youth work

Funding is provided by Bristol-Myers Squibb "Secure the Future" project as well as from numerous donors and partnerships.

BOCAIP "exists for the purpose of developing and supporting a country-wide network of church-based Christian responses to effect positive behaviour change, and provide compassionate care and support to those infected and affected by HIV/AIDS."

This programme is very well designed and is having a positive impact within its target audience. The work of the organisation has drawn positive affirmation from UN agencies and Government organisations. It is highly replicable.

4.        HIV/AIDS and Youth

4.1.    Overview

Botswana has a very young population with 37.5% of the population aged 10-24 years, and 12% of the population aged 15 –19 years. It is a literate population of youth with a net primary school enrollment of 98%. 90% of these children will reach Grade 5 level.

ACCording to the "Progress of Nations 2000 Report," 1 in 3 young women and 1 in 7 young men aged 15 – 24 are infected with HIV. A teenager in Botswana today has a 90% chance of being infected with HIV during his/her lifetime. (UNAIDS Global Report on AIDS 2000)

A recent government report found that many Batswanas still believe the HIV/AIDS is a foreign disease which is not in Botswana or is only found in urban areas. Young people can be overheard in Gaborone bars joking that AIDS stands for American Initiative to Discourage Sex. Others even brand self-confessed people living with HIV/AIDS as liars, while the other tendency is to hide those who die of HIV/AIDS by claiming that they were killed by other diseases. (UN Integrated Information Network Interview August 2001).

One in three young women not living beyond their mid-thirties will have dire consequences for childcare and protection in the future. There may be insufficient caregivers.

There appears to be a high drop put rate from school either because of a need to work to supplement family income, or to assume adult roles in caring for infected parents and younger siblings.

Girls, especially, will increasingly be expected to stay home and care for sick family members. Sometimes very young children aged 8 –11, are caring for sick parents whilst the older children leave home to find work.

Whilst the traditional extended family system is still functional, it is important to proactively prepare for the time when this coping capacity becomes overwhelmed. Government social services may not be enough and there is need for child friendly community based programmes where children can be cared for and supported by people familiar to them and in familiar surroundings. This has been lagging behind policy.

4.2.    Sex Education in Botswana

Traditionally parents do not communicate any sex education to their children. Sex education to adolescents is provided by designated adults, most frequently relatives. It is considered a "taboo" for parents to be involved. However, urban migration and changing family relationships have contributed to the demise of this traditional instruction.

Sex education in schools is lacking. To date, despite policy introduced in 1993 to include HIV/AIDS education in the national curriculum, there is no evidence yet of its inclusion and there appears to be some resistance to its development.

Though life skills may be taught in some schools, these are all extra-curricula.

ACCording to the Director of Health Services of Botswana, Patson Mazonde, the government is in the process (September 2001) of introducing family health into the school curriculum to teach sex education in a "comfortable cultural approach."

The Careers Guidance Officer from the Ministry of Education stated in the "Botswana Gazette" (August 2001) that the government is considering compulsorily testing all prospective University student entrants.

Teenage pregnancies are extremely common in Botswana. In the sentinel survey studies carried out in antenatal clinics throughout Botswana, the number of unmarried pregnant youth is exceptionally high, aCCounting for over 78% of all clients and within this group the HIV prevalence is highest in all test sites with ranges from 39.2% -51.9 %.

Clearly there is urgent need to address issues of sexuality as they pertain to youth. If education programmes suCCeed in doing nothing more than encouraging youth to delay sexual debut, their vulnerability to HIV/AIDS can be substantially reduced.

4.3.    Secular Responses to Youth and HIV/AIDS

4.3.1.     BOTUSA

BOTUSA is a joint venture between the USA and Botswana through the Centre for Disease Control and the Ministry of Health. CDC has placed 4 professionals in Botswana to work with the government and NGOs to implement urgently needed services. Approximately 100 local technical and support staff have been mobilised to work on the epidemic.

With regard to youth work, it operates with an objective of behavioural change which is developed principally through 3 programmes:

1.    Radio Drama (Botswana Soap Opera)

This radio drama has recently been initiated and is currently engaging the public. The series focuses on culturally specific AIDS-related issues developed by CDC in collaboration with local partners. The theme is behaviour change.

2.    Total Community Mobilisation:

CDC co-sponsors with the government a "door-to-door" educational programme by Humana People to People , which is underway in 3 districts, and provides HIV education and condoms to households. It is an effective programme of one-to-one communication on HIV/AIDS issues.

(20% is funded by CDC and 80% by government).

3.    Youth Group YOHO "Youth Health Organisation."

This is a group of youth in their late teens to early 20s, trained as peer educators and in drama, who offer audiovisual/drama entertainment on the themes of VCT, Blood donation, MTCT, abstinence/faithfulness and safe sex. It is out-reach education with innovative approaches to youth education.

4.3.2.     Botswana Family Welfare Association (BOFWA)

BOFWA has offices and youth centres in Gaborone, Lobatse, Kanye, Mochudi and Maun. It operates through a multi sectoral approach and networks with organisations that share similar objectives. This includes networking with civil society, business community, Government and UN agencies and International donors. Churches could be involved.

BOFWA is a national organisation, registered as a voluntary organisation, established in 1998 and affiliated to the International Planned Parenthood Federation. It aims to promote and provide good quality reproductive and sexual health care for the youth.

The youth centres offer drop-in facilities for youth who can avail themselves of the leisure activities provided. Recreational facilities for youth are scarce and provide a draw card for the youth. At these centres, youth are also provided with information, through discussions, libraries and trained resource people, on issues about sexuality and reproductive health, family education issues, family planning, condom use, as well as opportunities for counselling.

Trained youth peer educators facilitate group discussions and some counselling and are also involved in community outreach. These outreach programmes cover topics such as adult sexuality, teenage pregnancy and HIV/AIDS. Outreach programmes include out of school youth who have fewer opportunities to aquire new knowledge than in school youth.

The programme advocates and lobbies government for recognition and appreciation of unmet sexual and reproductive health needs of youth, women and couples and for the removal of all legal, political, cultural and religious barriers to sexual and reproductive health.

BOFWA is seeking to provide clinical services in the form of treatment and management of sexually transmitted infections, a one-stop service for youth in a country that as yet has not developed 'youth friendly services' on any large scale.

This programme has many strengths and is easily replicable. Churches could adapt and provide many of these services as part of their youth outreach programme and thus meet some pressing and very real needs of the youth.

4.3.3.     Botswana National Youth C ouncil

The Botswana National Youth Council was established in 1974 to coordinate youth programmes run by government, private sector and NGOs. It is meant to advise government on youth issues and to collaborate with NGOs.

They are active in training per educators and for this purpose are frequently used by different church groups such as the ELCB.

A constraint that is very evident is the lack of appropriate training material to target especially vulnerable groups such as the out of school youth not catered for in mainstream campaigns.

4.3.4.     Reetsanang Association Drama

This organisation was founded in 1986 as a tool for development education. HIV/AIDS became top priority in 1997. It coordinates the work of 78 theatre-groups countrywide, involving 2500 artists, in activities that include a community HIV/AIDS education programme, a school-based theatre training and support programme and theatre skills training. This outreach programme also tackles gender relations and environmental education. Community theatre is a powerful media of participatory communication and education which is popular with audiences, particularly the youth.

4.3.5.     Association of Teachers Against AIDS (ATAA)

This association was formed with the purpose of educating teachers on ways and means of preventing the spread of HIV/AIDS in schools and their communities. It involves in-service training and workshops for teachers and other educators. ATAA promotes HIV/AIDS prevention awareness campaigns, drama and poster competitions and produces AIDS-training material including a newsletter for students called "AIDS Education Update."

It receives support from both UNICEF and the government.

4.4.    Involvement of Churches and Faith-Based Organisations in HIV/AIDS Programmes for Youth

Effective, appropriate and widely aCCepted HIV/AIDS programmes for youth, in school and out of school, are conspicuously lacking. Though many churches have youth programmes, both the scale and impact appears limited given the size of the youth population and the high seroprevalence in this group. Programmes for out-of-school youth and street children were hard to find. Programmes addressing reproductive health and human sexuality in youth were rare. Recreational facilities for youth seem few.

The following represents a "best practices" which is replicable and is meeting the real needs of youth:

4.4.1.     YWCA Teenage Mothers and Peer Approach to Counselling by Teens (PACT)

The YWCA is a national programme affiliated to the International Youth Foundation and networks with local schools and civic society organisations. Since its inception in 1962, the YWCA has established 94 clubs countrywide. It has a major focus on youth, particularly girls, teenagers, in and out of school youth and teenage mothers. It also has a strong focus on advocacy and lobbying for women's empowerment and for teenage mothers. It is currently piloting a peer approach to counselling teenagers.

The YWCA is involved in an amazing range of activities as part of a development strategy in the areas of food production and preparation; employment creation; income generation; training; day care and water supply.

In 1988, in response to the alarming numbers of teenage pregnancies, the YWCA established a pilot project in Gaborone for 20 teenage mothers, 'to give them a second chance.' Over the year, through counselling, education and support for the babies, the girls were able to rebuild their self-esteem, learnt to care for their babies and to return to school. Inspired by the suCCess of the pilot for those who had been involved in it, the YWCA decided to initiate a new programme aimed at alerting young people to the risks to their sexual and reproductive health, and equipping them with knowledge and life skills to cope better with future challenges.

This new initiative was launched in 1990 as the YWCA "Peer Approach to Counselling by Teens (PACT)" programme, implemented to meet both local and cultural needs.

The PACT programme focuses mainly on in-school youth, who are easily aCCessible. Training is largely participatory and the contents are wide-ranging to impart both factual knowledge on human reproduction and sexuality, and skills in assertiveness, decision making, problem solving, goal setting and career choice. The peer educators are carefully selected, well trained and well supervised and supported.

The programme has achieved an impressive record and operates in a large number of secondary schools throughout the country. As Glen Williams states in his Strategies of Hope Series No. 12:

"PACT is a remarkable and important programme. At a time when the HIV epidemic seems to be assuming overwhelming proportions, often leading to feelings of fatalism and demoralisation, the PACT programme offers young people hope for the future. It is difficult to imagine where else the youth of Botswana could obtain such a comprehensive package of information and skills to guide them through an increasingly dangerous and rapidly changing world."

5.        HIV/AIDS and Gender Issues

Gender discrimination, inequalities, economic dependence of women on men and the formidably defended cultural and social norms make it difficult for women to refuse or negotiate for safer sex.

The incidence of teenage pregnancy is exceptionally high and much is due to gender imbalances. For example:

· Men are exploiting the economic challenges faced by young girls, who may be needing to find fees for schooling and other necessities, and capitalising on their vulnerability by exchanging money and goods for sexual favours

· It is said that women are coerced into sex in return for employment or advancement opportunities

· A young girl in a relationship with a fellow may be coerced into proving her fertility before marriage can be considered. Once pregnant, the girl is frequently abandoned and the fellow does not feel either obligations nor responsibility

· Low social status of women and cultural attitudes leave women (girls) in a poor-negotiating position with regard to sex.

· A considerable amount of unprotected sex is oCCurring if it is resulting in so many pregnancies. This calls for a re-look at the effectiveness of the HIV/AIDS prevention messages.

· A culture of silence hides the numerous episodes of sexual abuse and violence against women. This lack of response is evident from community level through to law enforcement agents and the courts.

The unwillingness of community leaders, in particular the churches, to speak out against these injustices enable the perpetuation of the situation and the 'protection' of those responsible.

Men, Sex and AIDS (Botswana) Project

The Men, Sex and AIDS Project is a relatively new project which has enormous potential.

Through workshops and group work the project aims to help men confront and understand issues of sexuality in a non-threatening environment of sharing with other men. Many factors influence behaviour such as environment, nurture, socio-economic status, past experiences, peer pressure and issues of self worth. "From discussions it is questionable whether promiscuity brings happiness to many men but it does bring a sense of power and control." It is issues like this, as well as responsibility for actions, that are explored and discussed.

There are far too few initiatives of this nature that aim to involve men in tackling gender issues and confront responsibility in the HIV/AIDS scenario.

6.        Invol vement of Churches in Training Clergy and Laity in Counselling of HIV/AIDS Infected and Affected

6.1.    Woodpecker

Churches have begun to recognise the need to incorporate training in counselling into the theological training of their clergy. Thus training facilities such as the "Woodpecker" Lutheran Seminary offer such a service.

6.2.    BOCAIP

The Botswana Christian AIDS Initiative (BOCAIP) is a 'best practice' in terms of the counselling curriculum it offers. It is a holistic approach whereby trainers are trained in the community in which they will be working. This six week training course is spread over six months and involves training in pretest, post-test and on going support counselling, family counselling and grief counselling. Other issues such as orphan care, home based care and support for people living with HIV/AIDS are all included in the training 'package'.

6.3      Tshepong Counselling Network

In response to the President's appeal for the involvement of Churches in the fight against AIDS, representatives from various churches met in September 1999 to initiate a wider, church-based effort to mobilise the Christian community. The objective was to promote cooperation between churches and the health services and existing structures, in addressing the AIDS problem across the capital city of Gaborone.

Volunteers from both independent and mainline churches who had been trained by BOCAIP, the Botswana Christian AIDS Initiative, met with leaders from evangelical, and pentecostal churches and the pastors fraternal to set up a steering committee to research the needs of Gaborone in regard to the AIDS crisis. They identified the need for counselling as an entry point to offer care and compassionate support, to influence society at large to destigmatise AIDS and finally to take appropriate measures to reduce its transmission.

Tshepong meaning "to hope / to trust." The counselling network operates through 14 clinics in Gaborone. Counselling takes place on a daily basis with individuals, married couples or families to provide emotional, spiritual, psychological and social support to enable clients to live positively with HIV/AIDS and to enable them to make informed healthy decisions about their future.

6.4.    Maun Counselling Centre

Maun Counselling and Social Support Centre is a community response to the ever increasing number of HIV infected and affected people. It is led by the Board of "Pastors Against AIDS." It was an outgrowth of the initial AIDS awareness and prevention campaigns started by the Pastors against AIDS with the objective of offering in addition social support, counselling, care and prevention strategies.

Some of the activities include pre-test and post test counselling at the hospitals, HIV testing, home visit follow up counselling and family counselling. Support groups for people living with HIV/AIDS have been established and the first person in Botswana to publicly declare her HIV positive status, in April 2001, was a young woman who had been attending this Centre.

It was observed that many clients seek help from traditional healers and prophets before seeking help elsewhere. In many instances, the treatment received severely compromised the condition of the patients, particularly when dehydration techniques were being routinely used. The Maun Counselling Centre decided to work with these traditional healers to share information about HIV/AIDS, the objectives of the Centre and to elicit their cooperation with infected patients. A positive response was received and the work of the Centre is now further respected.

An income generating project and community outreaches are well established.

All these initiatives are carried out in a spirit of cooperation between the churches and stakeholders and with obvious compassion for the infected and affected communities. There is much to be learnt from organisations as committed as this one.

7.        Care and Prevention Services

7.1 Voluntary Counselling and Testing Services (VCT)

BOTUSA, a joint venture between the USA and Botswana involving the Centre for Disease Control and the Ministry of Health, has established a network of testing centres called Tebelopele "to look into the future." This forms part of the Life Initiative within the Global AIDS Program whereby US $7-8 million per year have been designated in the areas of prevention, care and infrastructure and surveillance. The VCT plan is to have 15 free standing centres, all NGO based, and thus far 7 have been opened. The first centre was opened in April 2000 and since then 15 000 clients have passed through. Approximately 1 000 clients per month are now coming forward for testing.

Because the level of stigma is so high, BOTUSA efforts to reduce stigma are directed at involving people who are HIV positive and encouraging them to inform a circle of family and close friends. The hope is to form many of these circles and thus ultimately everyone will know someone who is HIV positive and thus reduce stigma.

Though Churches are very involved with the provision of counselling services, both pre-test and post-test, not many are actually involved in the provision of testing services. An exception is the Maun Counsellling Centre which provides a rapid test. There appears to be an increasing

demand for voluntary counselling and testing. If anti-retroviral agents become readily available, the demand will be even greater and stakeholders in HIV/AIDS programmes need to be ready.

7.2.    Prevention of Mother–to–Child Transmission (PMTCT)

Sentinel surveillance studies carried out at antenatal-clinics show that young women have infection rates of 39.2% and up to 51.9% in some places. These women have a high chance of transmitting HIV to their babies during pregnancy, delivery or in subsequent breast-feeding. In fact, 34% of paediatric admissions and 70% of paediatric hospital deaths are HIV related.

With an annual birth rate of 48-65 000 births, approximately 7-9 000 infants are likely to be infected each year.

Botswana 's PMTCT programme started in 1998 with the establishment of a task group, an annual budget of US $3.5 million, and UNICEF committed itself as one of the main partners. Piloting started in April 1999 and scaling up was nationally planned to start in July 2000 with the intention of covering the whole country by 2002.

The programme is population based (the first one in Africa) with a high level of Government commitment. PMTCT is being integrated into ANC services of a high standard in a strong health care system with good laboratory services.

Although PMTCT interventions are now offered in most health units in Gaborone and Francistown, uptake of PMTCT is still very low. Fear of HIV test results inhibits the promotion and aCCeptance of the programme. Constraints identified suggest that the IEC strategy for both the public and health workers is not sufficiently developed and as a consequence, the IEC messages have been unclear and inadequate. Health workers are not clear on the infant feeding message to be conveyed. Further, counselling is inadequate in terms of availability, content and quality. By 2000, only one half of ANC clients had been counselled and less than half agreed to testing.

Consultations are underway for universal aCCess to Nevirapine, without testing, for any mother and her baby who presents in labour for the first time, not having attended antenatal services.

There are parallel efforts to build up the counselling capacity and testing services particularly in geographic areas where the prevalence is high.

BOTUSA is highly committed to the PMTCT programme through four key areas namely:

1.    Infrastructure

BOTUSA has provided 200 "porter campers" to clinics. These are 2 –roomed portable structures to assist in providing space and privacy for counselling at clinics i.e. counselling in PMTCT, testing and breast-feeding.

2.    Audiovisual

A video has been developed which is shown at ANCs as this has been found to be an efficient way of communicating information to large numbers of clients simultaneously.

3.    Testing (see under section on VCT above)

4.    IEC

BOTUSA is developing quality material for counselling training, monitoring and evaluation.

7.3.    Christian Hospital Care

7.3.1.     Association of Medical Missions of Botswana

Initially the association began as part of the Botswana Christian Council's work but eventually developed into a fully-fledged association. It was registered in 1973.

It consists of the following mission hospitals and mission related institutions in Botswana:

· The Scottish Livingstone Hospital

· Bamalete Lutheran

· Deborah Retief Memorial Hospital

· St. Joseph 's Mission Hospital

· Seventh Day Adventist Hospital

· Mission Dental Service

· Botswana Adventist Medical Services

· Flying Mission

· Society for the Deaf

· St. Conrad's Mission Clinic

· Sehitwa Lutheran Clinic

· Thuso Rehabilitation Centre

· Lekgotla La Dikereke la Twantsho Ditagi

Educating people about AIDS and its prevention is one of the top priorities of the AMMB. The AIDS project is a national campaign through churches. The AIDS working party conducts workshops, produces pamphlets, videos, posters, poetry and other means of communication about AIDS.

It trains counsellors, nurses and pastors, in pastoral counselling. It also coordinates support groups, caregivers and PLWAs.

7.3.2.     Hospice Services and Home Based Care

In 1992 the concept of home based care was introduced in response to increasing pressure in hospitals with AIDS patients. The aim was to link state support with community based initiatives whereby families, supported by social welfare and the local community, would provide care in their homes to affected individuals.

In 1994, two pilot projects were launched which lasted only a year through lack of support. A special community home based care (CHBC) section in the AIDS / STD Unit was established to assist districts wanting to establish community home based care projects.

The Health and Local Government Ministries are responsible for the care and welfare of orphans and AIDS patients. The Social and Community Development Department of the Ministry of Local Government is responsible for providing food rations for orphans and AIDS patients on home based care. The Minisrty of Health is responsible for providing AIDS patients on home based care with gloves, bed pans, disposable nappies, detergents and more.

The extension of community home based care across Botswana, however, has been uneven and very patchy. Poverty presents severe constraints to communities offering any substantial care and may aggravate the risk of infection for already compromised patients. Many families have been left to care for ill relatives without any outside assistance or support.

To fill the gap, over 60 community home based care programmes run by NGOs and Churches, have been established.

Notable examples include: The Bobirwa Home Based Care Project, Kgatleng, Tutume, Bamalete, Lutheran Mission Hospital, Princess Marina Hospital, Gabane, Molepolole and Holy Cross Hospice.

It is estimated that, at any one time, there are approximately 5000 people on home based care.

The Ministry of Health AIDS/STD Unit has produced some excellent manuals on home based care for facilitators, trainers of trainers, caregivers and support groups as well as a guide to the assessment of clinic and family in home care.

The 5 modules cover the entire spectrum of the continuum of care. The modules, based on the belief that the family is central to the provision of care, psychosocial support and other forms of care, emphasise the empowerment of the family for self-care.

The modules also aim to mobilise community support for care and social support, seen as another essential element for the continuum of care.

Retired nurses have been deployed in home based care centres at the expense of the Government. Transportation in the form of motorbikes is being provided for those working in difficult areas.

7.4.    Care of Children Orphaned by AIDS

7.4.1.     Orphans in Botswana

ACCording to Census Bureau experts in the Children on the Brink Report of 2000 (Hunter and Williamson) Botswana currently has 67 455 maternal and double orphans from all causes, this represents 10.5% of children under 15 years. Adding paternal orphans to these figures raises the total orphan figure to 149 900 or 23.4% of all children under 15 years. The projections for 2010 are even more chilling. It is estimated that by then, the total orphans as a percentage of children under 15 years of age will have risen to 36.42%, equivalent to one in three children orphaned within this decade.

In 1998 the Botswana Ministry of Health commissioned a rapid assessment of the orphan situation in the country. A total of 4 496 orphans were registered in 10 villages and towns and the majority were aged between 11 and 15 years old. 30% had dropped out of school. 23 were child headed households with many of these orphans having lost parents and second and third generation caregivers as well.

In most cases their aCCess to basic needs i.e. food, clothing and decent shelter was considered a privilege but not a right. Orphans dropped out of school most often when caregivers could not afford to provide school uniforms, shoes, school feeding money or money for building funds. "AIDS orphans" also dropped out of school as a result of stigmatisation, rejection and isolation by other students and oCCasionally by teachers.

Many critical needs were identified in this study. Amongst those was the need for counselling to enable the orphans to cope with the emotional stress of losing parent/s, to deal with their fears of infection and to make informed decisions. A further need was to equip children, who are providing care, with basic home care skills.

A Children' Forum was held in April 2001 followed by the legislation of a new Bill called the "National Children's Act" which contains most of the legal provisions concerning children, including orphans and vulnerable children, in Botswana.

Several child-related committees exist in government. There is a National Child Welfare committee. Under NACA, which is chaired by the President and Ministers, there are several sector committees, one of which deals with orphans.

Each committee considers that they have the discreet role for the care of children. The public sector would like these committees to merge and strengthen for the sake of all children, not just the 'orphans and vulnerable children.'

Based on the size of the epidemic, it is estimated that there must currently be approximately 67 000 orphans within the community. However, to date only 25 000 have been registered.

Even though all registered orphans are entitled to a regular food basket, it appears that there is a resistance to registration because of the ensuing stigma. There is fear that the presence of an orphan would 'type-cast the family as having HIV/AIDS.'

Furthermore, it appears also that not all registered children, eligible to receive a food parcel, are in fact benefiting from this state provision. In theory, no one should starve. In practice, there is a lag time from orphanhood until the state becomes aware of the situation. The registration process is tedious. Although there is policy to provide short-term relief whilst the processing takes place, this does not seem to be happening. Evaluation of child's situation has to be ratified by the Council and debated before food parcels are delivered.

The Social Welfare officer reports to the District Councillors who report to the District Commissioner. It is within this chain that bottlenecks oCCur which cause delays in service provision. Some caregivers go for months without relief.

At the same time, it appears that members of the public are unable to challenge the information given to them, or the decisions taken by social workers. Communities are not very aware of their rights, or the rights of the child.

If NGOs, CBOs and Churches could work together in partnership to advocate, and to facilitate the registration process and to ensure food delivery, it could ease some of the bottlenecks and speed up the process of ensuring relief reaches those in need. This would also free the social workers from a large load of administrative work to pursue the real need of case studies and psychosocial support.

However, though at the level of the community, this support and partnership assistance would be greatly welcomed and appreciated, Government is reluctant to 'lose control.' There also seems to be, generally, a limited appreciation of the true size of the problem. There is a real need to 'unlock' social services.

In order to place children into institutions, again, the bureaucratic nightmares faced by social welfare officers unduly delay the whole process. This is born out by the fact that many child institutes have capacity beyond the number of children in care despite of the obvious need and demand for care within them.

Village AIDS Committees, under the auspices of the District Multi Sector AIDS Committees (DMSAC), are involved in service delivery and have set up day care centres at village level. These are in reality a spontaneous response to the situation of increasing numbers of child headed households. These day care centres offer both material support and psychosocial support to the orphans.

A "National Situational Analysis on Women and Children in Botswana" is currently underway. Perhaps these issues will then be highlighted and leave room for necessary partnerships to cope with the increasing demands of increasing numbers of orphans and vulnerable children. Churches need to be far more aware of potential roles they can play and to advocate for the rights of these children.

OVC Reflection Group

The OVC Reflection Group, started in September 2000, is a forum for anyone interested in issues relating to orphans and vulnerable children in Botswana. The group meets monthly and is chaired by a different member each month. In depth discussions and field visits are regularly undertaken to visit projects of interest to the group and for exposure to 'best practices.' UNICEF provides secretarial and financial support.

This is a very valuable forum and could easily be replicated in other centres and in churches.

7.4.2.     Models of Care

Models of care for orphans can be classified as follows:

· Independent living by orphans

· Independent living with external supervision and support

· Foster care including traditional family care, cluster care of multiple children, collective care of individuals or multiple children

· Adoption

· Institutional care including places of safety, shelters, short-term infants homes and traditional children's homes

· State or NGO sponsored community-based support structures including feeding centres and day care facilities.

(SALC, Project Committee on the Review of the Child Care Act; Consultative Paper on Children Infected and Affected by HIV/AIDS 1999 )

In Botswana the extended family system is still very functional and is the prime source of care for children orphaned from whatever cause. Where this system breaks down, Child Institutes are available provided principally by Government. Many communities, NGOs and Churches see the provision of institutes as the answer to the increasing numbers of children without traditional family support. International and regional recommendations, that institutions are not the best option, are culturally inappropriate and not sustainable given the magnitude of the crisis, have not yet been adopted by stakeholders in the field. Thus community based initiatives, which could be developed to meet the need, are not adequately being pursued with the urgency that the situation warrants. The efficiency of the functional extended family is concealing the magnitude of orphanhood from the general populace and creating a false sense of security about the size and impact of the problem.

A major "wake up" call is needed to the coming serious huge problem of orphans in need of care and the need to develop community based initiative to cope.

To their credit, Botswana has developed numerous drop –in, day care centres which are fulfilling a real need and are highly replicable in churches, by NGOs and even in the business sector.

7.4.3.     Institutional Care

SOS Children's Village

An example of institutional care in Botswana is the SOS or "Social Societies" Village in Francistown which was opened in 1998 and has the capacity to offer residential care to 150 children. The average age of the children in care here is 8 years (3-10 years).

The village system is based on 'houses', rather than the usual institutional dormitory system, each able to aCCommodate up to 10 children of varying ages with a "mother" who cares for them assisted by an "auntie." On reaching adolescence, children are moved into single sex "youth groups" where they take personal responsibility for cooking, cleaning and financial affairs.

The village employs a social worker and includes a community day-care centre for pre-school children, from both SOS Village and the surrounding areas. Older children from the SOS Village attend local schools. The Director, social worker and "mothers" are all trained to impart life-skills and HIV/AIDS prevention information to the children.

Children are encouraged and assisted to strengthen ties with their extended families, and are placed in their custody wherever possible.

7.4.4.     Community Care

The following is an excellent example of a community based support programme for orphans that provides peer support:

Tshireletso/Shining Stars

Tshireletso AIDS awareness Group, formed in March 1999 and operating in the poor township of Monarch in Francistown, is a community based organisation. Its members reach out to their community through mass education on HIV/AIDS, and support orphans and vulnerable children through feeding, education and counselling.

Tshireletso established a peer-support group of children aged 2-18 who call themselves "The Shining Stars of Monarch." Membership stands at 250 and is open to orphans under 18 years of age. Non-orphans are also encouraged to join, to provide support to OVC, but are subject to a probation period to show their commitment. The group helps its members to face grief, isolation and delinquency.

Many of the Shining Stars' activities centre on education, schooling and life-skills. Socially they regard themselves as one family, supporting each other in time of need. They have established recreational groups for dancing, singing, gardening, drama, soCCer and netball, and are involved in fundraising and networking with churches and schools.

Tshireletso has acquired a large plot of land and is building a multi-purpose centre to provide pre-school and day-care facilities, library and income-generating activities.

The strength of this programme, and the reason for inclusion in this report, is its grass root origins and an out-reach of youth to youth. When youth reach out to youth , it is the hope for the future, particularly when affected youth take responsibility for their own concerns and reach out to other affected children. Peer support, of this nature, can make a major impact on counteracting the stigmatisation of orphanhood and HIV/AIDS.

7.4.5.     Churches' Responses to Orphans and Vulnerable Children (OVC)

A number of home based care programmes include orphan support as a continuum of the services that they offer. Home Based Care is an excellent aCCess point to children in need and provides a chance to encourage the infected parent to make plans for the future of their children as well as to communicate with their children about their illness.

Numerous day care centres are run by faith based organisations. These centres provide daily care for orphans, particularly for those in desperate need, suffering from poor nutrition and lack of care and attention. The centres seek to enhance the physical, mental, emotional, social and spiritual development of the child by providing the children with food, love, care and medical treatment. The centres generally cater for children aged 2 – 7 years (pre-schoolers) and for school going children in the afternoons.

Children are referred to these centres by social workers or counsellors from the local counselling centres. Nurses from local hospitals check the health of the children.

Home visits to the orphans' homes help assess the conditions and reason for referral as well as present an opportunity to counsel family members.

Day Centres of this nature provide a safe haven for vulnerable children and ensure they receive basic food, nutrition and supervised care during the hours they are there. At the same time, these centres relieve the burden of responsibility from the caregivers who are thus freed to pursue options that improve their economic base, or simply to enjoy some respite from the demands of care.

7.4.6.     Street Children

There are five types of children who live on the streets:

1. Runaways: children who run away from home for at least one night without parental permission

2. Homeless children: children who are forces out of home and have no parental, substitute, foster or institutional home

3. System kids: children under the supervision of the State because of abuse, parental neglect and other serious family problems

4. Street kids: children who are long term runaways or homeless children who fend for themselves on the streets

5. Missing children

(American National Network Report 1985)

Street children are not very visible in Botswana though that is not to say they are not there. There are numerous immigrants in the border towns of Botswana, particularly on the border with Zimbabwe. Many of these immigrants are illegal, economic and political "refugees" and as such cannot aCCess state support in their time of need. The children of these communities are very vulnerable.

Street children are prime targets for HIV infection both because of a lack of knowledge and awareness and because of their low status, powerlessness and social conditions.

An example of a project for street children is the Botswana Christian Council Project at Old Naledi.

8.        Other Community Mobilisation Programme (CMP)

A unique programme has been established called the Community Mobilisation Programme. Young people are employed to go house to house, door to door, discussing issues of HIV/AIDS, assessing problems within the household and informing the oCCupants of the kind of help that is available for them and how to aCCess this help. This grass roots approach is having a very positive effect, is effectively mobilising people and is highly replicable.

The programme is supported by the government and BOTUSA.

9.        Observations and Recommendations

The magnitude of the epidemic warrants a phenomenal response. Though the Government is extremely active and supportive, there are simply not enough people in the public sector with the necessary expertise to action what is policy. Botswana lacks medical schools and public health schools and thus much of the expertise needed.

Botswana is a society which builds consensus before action. This is a cultural fact. Where there is disagreement over an issue, it may lead to protracted delays in reaching consensus. This may result in a bottleneck to decision-making, policy implementation and delivery of services.

Despite the relative affluence of the country, 47% of the population still live below the poverty datum line. Thus in relation to HIV/AIDS, poverty is an issue which affects sexual practices. Moreover, the population is highly mobile with large segments of the population having disposable income. Alcohol abuse is associated with increased risk for HIV/AIDS. This is difficult to tackle politically. Given the very high levels of sero-prevalence, the level of stigmatisation is remarkable.

There are insufficient anti-AIDS programmes specifically targeted at youth. Recreational facilities are limited and unoCCupied youth are drawn into bad practices.

Home based care programmes often act simply as referral systems for terminally ill and orphans to the appropriate ministries for assistance. Most operate in partnership and most are funded in part by the government. Most programmes link home based care with orphan care. There is a strong spirit of volunteerism though a definite lack in home based care skills and counselling skills. This is coupled with a lack of transport thus hampering service delivery.

With regard to orphans: funding agents such as USAID are not active in Botswana. Orphans receive from Government P200/month (= US $40.00). The financial support is given to the extended family so, technically, no orphan should go unclothed or unfed. They may be unloved but physically and materially they are catered for.

The system breaks down where:

- families are afraid of the stigma of admission to the presence of an orphan and thus not aCCessing support

- At the level of the social worker. If the attitude of the social worker is prejudiced, things may bottleneck through unreasonable delays.

- The largest number of orphans cared for under any programme contacted was 1600. This surely must represent only the tip of the iceberg and concern is that both identification of children-in-need and support coverage is far too limited, given the magnitude of the crisis. Though the extended families are obviously very functional at this time, it will not be long before their capacity is overwhelmed and children begin to fall through this safety net.

- A sense of urgency and priority to establish community based care for orphans is lacking.

- NGO's are generally weak because the Government has tended to provide all the necessities. Moreover, Botswana was declared a "middle-income status" country and thus many donors withdrew from the country. This left the NGOs without the technical and financial capacity to meet the rising demand for services. NGOs suffer from high staff turnover with loss of continuity of experience.

- Monitoring and evaluation is not good in NGOs and CBOs and there remains an inefficient interface with Government.

With particular reference to Churches, key issues emerged that need response:

- A sense of urgency is seriously lacking

- Few churches have a "Mission Statement on HIV/AIDS"

- Pastors / priests are not sufficiently equipped with the tools they need to cope with all the issues raised by HIV/AIDS.

- Clergy need to understand the wider implications of HIV/AIDS in order to plan for the future. For example: the impact on the population pyramid, the increase in numbers of orphans and the problems this will cause, urbanisation of the population leaving increasing numbers of elderly and orphans in the rural areas, without traditional support systems.

- Churches need to get involved with government structures and UN agencies to elicit necessary information and to make themselves available to meet appropriate needs

- Initiatives though noble are far too small. Many are personality driven and not backed by Church policy. This makes the programmes vulnerable to collapse if the key drivers leave.

- The responses are largely unconnected and often muted

- Churches believe they haven't the resources, human, financial and logistical, necessary to drive effective programmes. They are not seriously investigating other sources of funding or tapping into donor resources or partnerships with other organisations which can provide necessary expertise

- Churches could break the bottlenecks in service delivery from government sources

- Churches are not "Breaking the Silence"

- Churches are not using their powerful advocacy tool

- The stalemate over condoms is not constructive and may compromise the churches' credibility as an organisation that is serious about its response to HIV/AIDS. This is particularly true where the inability to reach some form of consensus over the condom issue means that nothing else is done.

- The Church is not addressing sexuality or gender issues that are contributory factors to the spread of HIV/AIDS

- There are insufficient programmes targeted specifically at youth / sexuality / sex education and reproductive health

- Youth-friendly health services are extremely rare

- The care of "carers" needs urgent attention as this is a very neglected area

- Psychosocial support for orphans, carers and affected communities is lacking

- There are too few support groups for people living with HIV/AIDS

- Churches are well placed to promote, develop and support community based care of orphans and should actively promote this.

Churches could do so much to de-stigmatize HIV/AIDS and promote awareness and education. The Botswana people are conservative and need to really understand issues and need to be involved if they are to support initiatives.

The question that looms large is why, in a country where the government is so committed to responding to the problem and has mobilised all its resources to tackle the problem, is there so little impact? Is it possible that the biggest problem is the lack of coordinated and committed church effort? Is denial within the church at the local level a problem? What messages are the churches communicating to their congregations?

In Uganda, when HIV/AIDS struck, it was one of the poorest countries in the world. The State and the Church stood together in the fight against AIDS. In Botswana, the church is very fragmented into small initiatives operating at local level. With few exceptions, responses are muted and uncoordinated.

The government has recognised the crucial role churches can play and has appealed for their help. It was declared that since most Batswanas identify themselves with a church, the various churches thus represent the most persuasive grass roots network in the country. Churches, sufficiently committed and well informed, could motivate and mobilise communities to seriously address these life-threatening issues.

Political commitment from Government, together with resource allocation, can never be enough to challenge attitudes and inspire personal responsibility for behaviour and actions in the nation. It needs to move hand in hand with mobilised communities.

The challenge is for the extensive and diverse network of churches to pull together to make HIV/AIDS a common agenda and to network with other major players in a meaningful way in order to begin to make a difference.

In summary the following are recommendations that may focus what churches can do in order to mount an effective response to HIV/AIDS:

A. Information

· HIV/AIDS
Churches need a better understanding of the epidemic, both currently and the future projections and implications. There is need for a better awareness of the situation as it pertains to Botswana as well as knowledge of all the relevant current legislation, state services and how to aCCess these services for the community

· Establish a Data Base of organisations working in the different fields of HIV/AIDS and services available

· Convention on the Rights of the Child: ensure clear understanding and advocate for these rights.

· Best Practices: Identify existing models of HIV/AIDS awareness, prevention, care and support programmes and share experiences

B. Policy

Develop a policy framework on HIV/AIDS to be adopted throughout the church from seminaries to local parishes. It is imperative that the condom issue does not create an impasse that paralyses action, for neither the State nor the Church is winning the battle against AIDS.

C.  Strategy

Develop appropriate strategies. Ensure these include:

· Situation analyses of communities served

· Community participation in identification of needs and design and implementation of

· programmes to ensure community ownership

· A holistic approach of care and support that addresses a comprehensive continuum of physical, emotional, spiritual and social need

· Gender issues

· Focus on youth, including issues of sexuality and reproductive health

· Integration of poverty alleviation strategies

· Specifically overcome denial of HIV/AIDS and stigmatisation of PLWA

· Monitoring, evaluation and feedback to the communities

D. Network-Coordinate-Communicate

· Churches

· Government

· UN Agencies

· NGOs and CBOs

· Private Sector

· Donor Community

Share technical, financial, and human expertise – we don't have to do everything ourselves

Avoid overlap and under-lap and clearly establish effectiveness areas for each stake-holder.

E.  Denial and Discrimination

Actively work to reduce/end discriminatory practices with regard to HIV/AIDS in Gender, workplaces, schools and churches and against PLWA and orphans.

F. Advocacy

Advocacy for the rights of the communities served. This includes advocacy on issues such as VCT, PMTCT, and Anti-Retroviral Therapy.

F. Community Mobilisation

Community mobilisation within and without the church, locally, regionally

and internationally

G. Be Christ to One Another

References and Bibliography

Amanze J.N.: Botswana Handbook of Churches 1994

BONASA: Botswana Network of AIDS Service Organisations 2000

Community Home Based Care Sub Unit AIDS/STD Unit Ministry of Health: Directory of Community Home Based Care Service Providers 1999

Government of Botswana and UNDP: Botswana Human Development Report 2000

Hunter S and J. Williamson: Children on the Brink 2000, Washington D.C: USAID

Kenyon T: CDC GAP HIV/AIDS Country Report 2001

Khan B: Comprehensive HIV/AIDS Partnerships in Botswana. Presentation to the "Meeting on AIDS Care in Africa" Rockefeller Foundation – Kampala Uganda April 2001

Muchiru SM: The Rapid Assessment on the Situation of Orphans in Botswana 1998

(Roodt V.: Tourist Guide to Botswana 1998 Shell Oil Botswana)

SADC Regional Human Development Report 1998: UNDP, SADC, SAPES

Smart R.: Children Living with HIV/AIDS in South Africa A Rapid Appraisal NACTT, SCF(UK)

UNAIDS: Report on the Global HIV/AIDS Epidemic June 2000

UNICEF: The State of the World's Children 2001

Williams G., Milligan A., Odemwingie T.: A Common Cause Strategies of Hope Series No.12 1997