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“Test and Treat”; cautioning on the conundrum of treatment compliance in chronic diseases

It has recently been announced that it is now recommended by WHO, other Agencies and Global Health Initiatives that countries should now move to a policy of putting all people living with HIV on Anti-retroviral therapy (ART) irrespective of their CD4 count. We should recall that criteria for treatment have changed over time, the main one being the level of CD4 count, but also based on viral loads and on presence of AIDS defining conditions (diseases such as TB, Pneumonia (PCP) or Herpes zoster conditions).  The CD4 criteria are the ones that have changed most over time, starting with 200, then 350 and now the recommendation being to start ART irrespective of CD4 count or any other criteria for that matter.

This decision to treat all HIV positive individuals is scientifically sound. It has the greatest potential to control HIV/AIDS in the long term, because it can reduce HIV related disease and AIDS to a minimum, and most importantly, in reducing viral loads to undetectable or very low levels, would render most people living with HIV non-infectious. This is the scientific basis.

There are however negative unintended complications to think of. The one that people talk about most is the cost; can Botswana, with its high HIV prevalence rate (the second highest in the world), afford to have such a large number of people on ARVs? This is despite the fact that the price of the drugs has been falling. Already, even with the current treatment criteria, the impact on the fiscus is being felt, with many people regarding the ARV treatment as unsustainable.

The other unintended consequence, which worries those like me more that the fiscal sustainability, is the question of treatment compliance.  Human beings don’t like taking tablets for long periods of time. We all know that many people can hardly complete a 5-day course of antibiotics. We have seen what happens to compliance in cases of chronic diseases, such as TB, diabetes, hypertension, and indeed in ART itself. Many patients simply get tired and stop taking treatment; they either get lost to follow-up, or in some cases they continue collecting the drugs but don’t actually ingest them.

The idea of “Test and Treat” is indeed very attractive and exciting, and that is why some in the press in Botswana are already asking when Botswana is going to implement it. But we have to learn from experience in other chronic diseases to predict its chances of success. It is, as indicated above, a scientifically solid idea, but its success in entirely dependent on human behaviour.

And we know that in the fight against HIV/AIDS, (and other diseases), it is the human behaviour, not the effectiveness or ineffectivess of drugs that has been the source of failure. In the fight against HIV/AIDS itself, we know that in the last three decades that we have been fighting the disease, human sexual behaviour in Botswana has changed very little. Multiple concurrent partnerships, intergenerational sex, transactional sex, early sexual debut, non-use of condoms, and other negative behaviours have persisted despite intensive education. There are still a lot of teenage pregnancies, resulting in a high school drop-out rate. Behavioural change communication has not been a roaring success.

We also know that whereas initially treatment compliance with anti-retroviral drugs (ARVs) was good, now there are many lost to treatment, either by simply defaulting and not coming any more for treatment, taking treatment irregularly, or collecting the tablets and simply not ingesting them. This deterioration of compliance over time can be attributed to the fact that whereas early in the treatment with ARVs the patients started treatment when they were very sick, and could see that without treatment they were going to die (some were rescued from death at the last moment – sometimes described as the Lazarus phenomenon) now a large number of patients, because of new treatment criteria, start treatment when they don’t really feel sick, and therefore have little motivation to continue the treatment. We know also that some end up being persuaded by traditional healers or religious practitioners to stop their treatment. This does not only happen in HIV but also in Diabetic patients, TB patients and others.

This is the reason I am urging so much caution in the adoption of the new criteria of treating all HIV positive individuals, the so called “Test and Treat”. I have worked for almost four decades in Tuberculosis control, here at home and internationally, and nothing has challenged TB control like patient compliance. That is why WHO and its partners, especially the International Union Against Tuberculosis and Lung Disease (IUATLD), adopted supervised treatment in the 1980s, which later came to be known as DOTS (Directly Observed Treatment, Short Course) in the 1990s. It is the recommended way of delivering TB treatment internationally, especially in high burden countries, because when left to self-administer treatment, patients generally do not comply, resulting in low cure rates or treatment completion rates, and the rise in drug resistance.

Workers in HIV/AIDS should take the TB experience to heart. Although there is a vaccine used against TB (BCG which in Botswana is given at birth), the vaccine is not effective in controlling TB because it does not prevent the infectious form of the disease. In fact it is used only to prevent severe forms of the disease in childhood (such as meningitis and miliary TB). So the major way of preventing TB is the effective treatment of those suffering from the infectious form of the disease i.e. pulmonary (lung disease)TB in adults. So if patients default from treatment, they continue to be infectious, and in many cases, they develop the drug-resistant form of the disease because the microbes become resistant to the drugs; and they then spread the resistant organisms.  This has been the experience in many countries, including Botswana. Multidrug resistant TB is now a major problem in Eastern Europe and in Southern Africa among other places. This could happen to HIV.

Treatment of TB is relatively long but it is not for life. TB is curable. Up to the 1980s, treatment of TB took 18 to 24 months. After new more potent drugs came into the market in the 1970s, treatment of TB was reduced to six months. In Botswana we changed to these new drugs in 1984, far ahead of other African countries. The drugs were very expensive, and there was an international agreement that they were to be given only under full supervision, i.e., every dose the patient took had to be supervised and documented by a health worker. The critical drug for this was Rifampicin, so this new treatment was called Rifampicin-containing drug regimens, and it reduced the treatment time to six months, hence it was referred to as Short-Course Chemotherapy.  
Adopting fully supervised Short-Course Chemotherapy helped Botswana to drastically reduce the level of non-compliance with treatment (defaulting).  In a paper published in the British Medical Journal in 1992, titled “Case holding in patients with Tuberculosis in Botswana”, Kumaresan and Maganu (myself) demonstrated the dramatic impact of Short-Course Chemotherapy and daily supervised treatment. Treatment compliance rose to 92.3% and defaulting dropped to 7.7%. Before the introduction of Short-Course Chemotherapy and supervised treatment in 1984, treatment compliance was only 60%.

In fact, when I took over the National TB programme in 1979, there was no compliance to talk about; hardly any patient completed treatment.  Patients defaulted either by disappearing or collecting the tablets regularly but not ingesting them or ingesting them irregularly. Health workers used to visit patient’s homes and find large numbers of anti-TB tablets stored under beds and in similar places. Urine tests also used to prove that many patients were simply not ingesting their anti-TB drugs. So, few were cured. In a situation like that many TB patients either died or became chronic excretors of the TB organisms, infecting large numbers of people.

So the dramatic effect of introducing Short –Course Chemotherapy and supervised treatment was very obvious. Botswana introduced this form of treatment when only a few countries in Africa were doing it under sponsorship from donors as pilot projects; in our part of Africa it was Tanzania and Malawi that piloted the treatment. The treatment was adopted internationally under WHO leadership in the early 1990s and was called “DOTS” (Directly Observed Treatment, Short Course).  Unfortunately, the adoption of DOTS in Southern Africa, including Botswana, coincided with the HIV/AIDS epidemic, which resulted in a rapid rise of HIV-associated TB. Consequently the impact of DOTS in Southern Africa was not as good as in other parts of the world because of the HIV/AIDS epidemic. However, treatment outcomes improved dramatically because of great improvements in patient compliance. The percentage of TB patients classified as “Treatment success rate” (cured or completed treatment) rose drastically and was well documented as part of the DOTS monitoring system.

I have related the TB experience to illustrate the negative effect that can result from poor patient compliance with treatment. Putting large numbers of HIV positive people on ARV treatment when they are not ill needs to be approached with caution. In Botswana this implies well over 10% of the population on ARV drugs. TB treatment has a problem with compliance although its treatment is only six months. ARV treatment is life-long; how much more compliance problems are likely to occur? The effect of widespread defaulting from ART would be large-scale drug resistance and a need to use more and more expensive drugs. Morbidity and mortality would actually not be reduced.

The Government of Botswana should only adopt universal treatment of those who are HIV positive (the so-called Test and Treat) if new ways of promoting or ensuring compliance are found.

The TB establishment came up with DOTS; HIV workers don’t have to follow DOTS, but have to find a similarly innovative way of ensuring compliance before embarking on this new internationally promoted initiative.

The new treatment criteria for HIV, including the “Test and Treat” movement, is an integral part of the triple 90 initiative. It is all very scientific and noble, but if Botswana embarks on the initiative without taking care of the concerns mentioned above, it could end up in a very terrible disaster.

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Can we cure ourselves from the cancer of corruption?

28th October 2020
DCEC DIRECTOR: Tymon Katholo

Bokani Lisa Motsu

“One of the saddest lessons of history is this: If we’ve been bamboozled long enough, we tend to reject any evidence of the bamboozle. We’re no longer interested in finding out the truth. The bamboozle has captured us. It’s simply too painful to acknowledge, even to ourselves, that we’ve been taken. Once you give a charlatan power over you, you almost never get it back.” Carl Sagan

Corruption is a heavy price to pay. The clean ones pay and suffer at the mercy of people who cannot have enough. They always want to eat and eat so selfishly like a bunch of ugly masked shrews. I hope God forgives me for ridiculing his creatures, but that mammal is so greedy. But corruption is not the new kid on the block, because it has always been everywhere.

This of course begs the question, why that is so? The common answer was and still is – abuse and misuse of power by those in power and weak institutions, disempowered to control the leaders. In 1996, the then President of The World Bank, James D. Wolfensohn named the ‘C-Word’ for the first time during an annual meeting of the Bretton Woods Institutions. A global fight against corruption started. Transparency International began its work. Internal and external audits mushroomed; commissions of inquiry followed and ever convoluted public tender procedures have become a bureaucratic nightmare to the private sector, trying to fight red tape.

The result is sobering corruption today is worse than it was 25 years ago. There is no denying that strong institutions help, but how does it come that in the annual Transparency International Ranking the same group of countries tend to be on the top while another group of countries, many African among them, tend to be on the bottom? Before one jumps to simple and seductive conclusions let us step back a moment.

Wolfensohn called corruption a cancer that destroys economies like a cancer destroys a body. A cancer is, simplified, good cells in a body gone bad, taking control of more and more good cells until the entire body is contaminated and eventually dies. So, let us look at the good cells of society first: they are family ties, clan and tribe affiliation, group cohesion, loyalty, empathy, reciprocity.

Most ordinary people like the reader of these lines or myself would claim to share such values. Once we ordinary people must make decisions, these good cells kick in: why should I hire a Mrs. Unknown, if I can hire my niece whose strengths and weaknesses I know? If I hire the niece, she will owe me and support my objectives.

Why should I purchase office furniture from that unknown company if I know that my friend’s business has good quality stuff? If I buy from him, he will make an extra effort to deliver his best and provide quality after sales service? So, why go through a convoluted tender process with uncertain outcome? In the unlikely case my friend does not perform as expected, I have many informal means to make him deliver, rather than going through a lengthy legal proceeding?

This sounds like common sense and natural and our private lives do work mostly that way and mostly quite well.

The problem is scale. Scale of power, scale of potential gains, scale of temptations, scale of risk. And who among us could throw the first stone were we in positions of power and claim not to succumb to the temptations of scale? Like in a body, cancer cells start growing out of proportion.

So, before we call out for new leaders – experience shows they are rarely better than the old ones – we need to look at ourselves first. But how easy is that? If I were the niece who gets the job through nepotism, why should I be overly critical? If I got a big furniture contract from a friend, why should I spill the beans? What right do I have to assume that, if I were a president or a minister or a corporate chief procurement officer I would not be tempted?

This is where we need to learn. What is useful, quick, efficient, and effective within a family or within a clan or a small community can become counterproductive and costly and destructive at larger corporate or national scale. Our empathy with small scale reciprocity easily permeates into complacency and complicity with large scale corruption and into an acquiescence with weak institutions to control it.

Our institutions can only be as strong as we wish them to be.

I was probably around ten years old and have always been that keen enthusiastic child that also liked to sing the favourite line of, ‘the world will become a better place.’  I would literally stand in front of a mirror and use my mom’s torch as a mic and sing along Michael Jackson’s hit song, ‘We are the world.’

Despite my horrible voice, I still believed in the message.  Few years later, my annoyance towards the world’s corrupt system wonders whether I was just too naïve. Few years later and I am still in doubt so as to whether I should go on blabbing that same old boring line. ‘The world is going to be a better place.’ The question is, when?

The answer is – as always: now.

This is pessimistic if not fatalistic – I challenge Sagan’s outlook with a paraphrased adage of unknown origin: Some people can be bamboozled all of the time, all people can be bamboozled some of the time, but never will all people be bamboozled all of the time.

We, the people are the only ones who can heal society from the cancer of corruption. We need to understand the temptation of scale and address it. We need to stop seeing ourselves just a victim of a disease that sleeps in all of us. We need to give power to the institutions that we have put in place to control corruption: parliaments, separation of power, the press, the ballot box. And sometimes we need to say as a niece – no, I do not want that job as a favour, I want it because I have proven to be better than other contenders.

It is going to be a struggle, because it will mean sacrifices, but sacrifices that we have chosen, not those imposed on us.

Let us start today.

*Bokani Lisa Motsu is a student at University of Botswana

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Opinions

Accounting Officers are out of touch with reality

19th October 2020

Parliament, the second arm of State through its parliamentary committees are one of Botswana’s most powerful mechanisms to ensure that government is held accountable at all times. The Accounting Officers are mostly Permanent Secretaries across government Ministries and Chief Executive Officers, Director Generals, Managing Directors of parastatals, state owned enterprises and Civil Society.

So parliament plays its oversight authority via the legislators sitting on a parliamentary committee and Accounting Officers sitting in the hot chair.  When left with no proper checks and balances, the Executive is prone to abuse the arrangement and so systematic oversight of the executive is usually carried out by parliamentary committees.  They track the work of various government departments and ministries, and conduct scrutiny into important aspects of their policy, direction and administration.

It is not rocket science that effective oversight requires that committees be totally independent and able to set their own agendas and have the power to summon ministers and top civil servants to appear and answer questions. Naturally, Accounting Officers are the highest ranking officials in the government hierarchy apart from cabinet Ministers and as such wield much power and influence in the performance of government.  To illustrate further, government performance is largely owed to the strategic and policy direction of top technocrats in various Ministries.

It is disheartening to point out that the recent parliament committees — as has been the case all over the years — has laid bare the incompetency, inadequacy and ineptitude of people bestowed with great responsibilities in public offices. To say that they are ineffective and inefficient sounds as an understatement. Some appear useless and hopeless when it comes to running the government despite the huge responsibility they possess.

If we were uncertain about the degree at which the Accounting Officers are incompetent, the ongoing parliament committees provide a glaring answer.  It is not an exaggeration to say that ordinary people on the streets have been held ransom by these technocrats who enjoy their air conditioned offices and relish being chauffeured around in luxurious BX SUV’s while the rest of the citizenry continue to suffer. Because of such high life the Accounting Officers seem to have, with time, they have gotten out of touch with the people they are supposed to serve.

An example; when appearing before the recent Public Accounts Committee (PAC), Office of the President Permanent Secretary, Thuso Ramodimoosi, looked reluctant to admit misuse of public funds. Although it is clear funds were misused, he looked unbothered when committee members grilled him over the P80 million Orapa House building that has since morphed into a white elephant for close to 10 successive years. To him, it seems it did not matter much and PAC members were worried for nothing.

On a separate day, another Accounting officer, Director of Public Service Management (DPSM), Naledi Mosalakatane, was not shy to reveal to PAC upon cross-examination that there exist more than 6 000 vacancies in government. Whatever reasons she gave as an excuse, they were not convincing and the committee looked sceptical too. She was faltering and seemed not to have a sense of urgency over the matter no matter how critical it is to the populace.

Botswana’s unemployment rate hoovers around 18 percent in a country where majority of the population is the youth, and the most affected by unemployment. It is still unclear why DPSM could underplay such a critical matter that may threaten the peace and stability of the country.
Accounting Officers clearly appear out of touch with the reality out there – if the PAC examinations are anything to go by.

Ideally the DPSM Director could be dropping the vacancy post digits while sourcing funds and setting timelines for the spaces to be filled as a matter of urgency so that the citizens get employed to feed their families and get out of unemployment and poverty ravaging the country.
The country should thank parliamentary committees such as PAC to expose these abnormalities and the behaviour of our leaders when in public office. How can a full Accounting Officer downplay the magnitude of the landless problem in Botswana and fail to come with direct solutions tailor made to provide Batswana with the land they desperately need?

Land is a life and death matter for some citizens, as we would know.

When Bonolo Khumotaka, the Accounting Officer in the Ministry of Land Management, Water and Sanitation Services, whom as a top official probably with a lucrative pay too appears to be lacking sense of urgency as she is failing on her key mandate of working around the clock to award the citizens with land especially those who need it most like the marginalised.  If government purports they need P94 billion to service land to address the land crisis what is plan B for government? Are we going to accept it the way it is?

Government should wake up from its slumber and intervene to avoid the 30 years unnecessary waiting period in State land and 13 years in Tribal land.  Accounting Officers are custodians of government policy, they should ensure it is effective and serve its purpose. What we have been doing over the years, has proved that it is not effective, and clearly there is a need for change of direction.

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Is it possible to make people part of your business resilience planning after the State of Public Emergency?

12th October 2020

THABO MAJOLA

His Excellency Dr Mokgweetsi EK Masisi, the President of the Republic of Botswana found it appropriate to invoke Section 17 (1) of the Constitution of the Republic of Botswana, using the powers vested in him to declare a State of Public Emergency starting from the 2nd April 2020 at midnight.

The constitutional provision under Section 17 (2b) only provided that such a declaration could be up to a maximum of 21 days. His Excellency further invoked Section 93 (1) to convene an extra- ordinary meeting of Parliament to have the opportunity to consult members of parliament on measures that have been put in place to address the spread and transmission of the virus. At this meeting Members of Parliament passed a resolution on the legal instruments and regulations governing the period of the state of emergency, and extended its duration by six (6) months.

The passing of the State of Emergency is considered as a very crucial step in fighting the near apocalyptic potential of the Novel COVID-19 virus. One of the interesting initiatives that was developed and extended to the business community was a 3-month wage subsidy that came with a condition that no businesses would retrench for the duration of the State of Public Emergency. This has potentially saved many people’s jobs as most companies would have been extremely quick to reduce expenses by downsizing. Self-preservation as some would call it.

Most organisations would have tried to reduce costs by letting go of people, retreated and tried their best to live long enough to fight another day. In my view there is silver lining that we need to look at and consider. The fact that organisations are not allowed to retrench has forced certain companies to look at the people with a long-term view.

Most leaders have probably had to wonder how they are going to ensure that their people are resilient. Do they have team members who innovate and add value to the organisation during these testing times? Do they even have resilient people or are they just waiting for the inevitable end? Can they really train people and make them resilient? How can your team members be part of your recovery plan? What can they do to avoid losing the capabilities they need to operate meaningfully for the duration of the State of Public Emergency and beyond?

The above questions have forced companies to reimagine the future of work. The truth is that no organisation can operate to its full potential without resilient people. In the normal business cycle, new teams come on board; new business streams open, operations or production sites launch or close; new markets develop, and technology is introduced. All of this provides fresh opportunities – and risks.

The best analogy I have seen of people-focused resilience planning reframes employees as your organisation’s immune system, ready and prepared to anticipate risks and ensure they can tackle challenges, fend off illness and bounce back more quickly.  So, how do you supercharge your organizational immune system to become resilient?

COVID-19 has helped many organisations realize they were not as prepared as they believed themselves to be. Now is the time to take stock and reset for the future. All the strategies and plans prior to COVID-19 arriving in Botswana need to be thrown out of the window and you need to develop a new plan today. There is no room for tweaking or reframing. Botswana has been disrupted and we need to accept and embrace the change. What we initially anticipated as a disease that would take a short term is turning out to be something we are going to have to live with for a much longer time. It is going to be a marathon and therefore businesses need to have a plan to complete this marathon.

Start planning. Planning for change can help reduce employee stress, anxiety, and overall fear, boosting the confidence of staff and stakeholders. Think about conducting and then regularly refreshing a strategic business impact analysis, look at your employee engagement scores, dig into your customer metrics and explore the way people work alongside your behaviours and culture. This research will help to identify what you really want to protect, the risks that you need to plan for and what you need to survive during disruption. Don’t forget to ask your team members for their input. In many cases they are closest to critical business areas and already have ideas to make processes and systems more robust.

Revisit your organisational purpose. Purpose, values and principles are powerful tools. By putting your organisation’s purpose and values front and center, you provide clear decision-making guidelines for yourself and your organisation. There are very tough and interesting decisions to make which have to be made fast; so having guiding principles on which the business believes in will help and assist all decision makers with sanity checking the choices that are in front of them. One noticeable characteristic of companies that adapt well during change is that they have a strong sense of identity. Leaders and employees have a shared sense of purpose and a common performance culture; they know what the company stands for beyond shareholder value and how to get things done right.

Revisit your purpose and values. Understand if they have been internalised and are proving useful. If so, find ways to increase their use. If not, adapt them as necessities, to help inspire and guide people while immunizing yourself against future disruption. Design your employee experience. The most resilient, adaptive and high performing companies are made up of people who know each other, like each other, and support each other.

Adaptability requires us to teach other, speak up and discuss problems, and have a collective sense of belonging. Listening to your team members is a powerful and disruptive thing to do. It has the potential to transform the way you manage your organisation. Enlisting employees to help shape employee experience, motivates better performance, increases employee retention and helps you spot issues and risks sooner. More importantly, it gives employees a voice so you can get active and constructive suggestions to make your business more robust by adopting an inclusive approach.

Leaders need to show they care. If you want to build resilience, you must build on a basis of trust. And this means leaders should listen, care, and respond. It’s time to build the entire business model around trust and empathy. Many of the employees will be working under extreme pressure due to the looming question around what will happen when companies have to retrench. As a leader of a company transparency and open communication are the most critical aspects that need to be illustrated.

Take your team member into confidence because if you do have to go through the dreaded excise of retrenchment you have to remember that those people the company retains will judge you based on the process you follow. If you illustrate that the business or organization has no regard for loyalty and commitment, they will never commit to the long-term plans of the organisation which will leave you worse off in the end. Its an absolutely delicate balance but it must all be done in good faith. Hopefully, your organization will avoid this!

This is the best time to revisit your identify and train your people to encourage qualities that build strong, empathetic leadership; self-awareness and control, communication, kindness and psychological safety.  Resilience is the glue that binds functional silos and integrates partners, improves communications, helps you prepare, listen and understand. Most importantly, people-focused resilience helps individuals and teams to think collectively and with empathy – helping you respond and recover faster.

Article written by Thabo Majola, a brand communications expert with a wealth of experience in the field and is Managing Director of Incepta Communications.

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