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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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Botswana to Become a Vaccinated Nation: Pandemic Anxiety Over?

30th March 2021

OSCAR MOTSUMI

This is a question that should seriously exercise the mind of every Botswana citizen and every science researcher, every health worker and every political leader political.

The Covid-19 currently defines our lives and poses a direct threat to every aspect and every part of national safety, security and general well-being. This disease has become a normative part of human life throughout the world.

The first part of the struggle against the murderous depredation of this disease was to protect personal life through restrictive health injunctions and protocols; the worst possibly being human isolation and masks that hid our sorrows and lamentations through thin veils. We suffered that humiliation with grace and I believe as a nation we did a great job.

Now the vaccines are here, ushering us into the second phase of this war against the plague; and we are asking ourselves, is this science-driven fight against Covid-19 spell the end of pandemic anxiety? Is the health nightmare coming to an end? What happy lives lie ahead? Is this the time for celebration or caution? As the Non State Actors, we have being struggling with these questions for months.

We have published our thoughts and feelings, and our research reviews and thorough reading of both the local and international impacts of this rampaging viral invasion in local newspapers and social media platforms.

More significantly, we have successfully organised workshops about the impact of the pandemic on society and the economy and the last workshop invited a panel of health experts, professionals, and public administers to advance this social dialogue as part of our commitment to the tripartite engagement we enjoy working with Government of Botswana, Civil Society and Development partners. These workshops are virtual and open to all Batswana, foreign diplomatic missions based in Gaborone, UN agencies located in Gaborone and international academic researchers and professional health experts and specialists.

The mark of Covid-19 on our nation is a painful one, a tragedy shared by the entire human race, but still a contextually painful experience. Our response is fraught with grave difficulties; limited resources, limited time, and the urgency to not only save lives but also avert economic ruin and a bleak future for all who survive. Several vaccines are already in the  market.

Parts of the world are already doing the best they can to trunk the pestilential march of this disease by rolling out mass-vaccinations campaigns that promise to evict this health menace and nightmare from their public lives. Botswana, like much of Africa, is still up in the disreputable, and, unenviable, preventative social melee of masked interactions, metered distances, contactless commerce.

We remain very much at the mercy of a marauding virus that daily runs amuck with earth shattering implications for the economy and human lives. And the battle against both infections and transmissions is proving to be difficult, in terms of finance, institutional capacities and resource mobilization. How are we prepared as government, and as citizens, to embrace the impending mass-vaccinations? What are the chances of us  succeeding at this last-ditch effort to defeat the virus? What are the most pressing obstacles?

Does the work of vaccines spell an end to the pandemic anxieties?

Our panellists addressed the current state of mass-vaccination preparedness at the Botswana national level. What resources are available? What are the financial, institutional and administrative operational challenges (costs and supply chains, delivery, distribution, administering the vaccine on time, surveillance and security of vaccines?) What is being done to overcome them, or what can be done to overcome them? What do public assessments of preparedness tell us at the local community levels? How strong is the political will and direction? How long can we expect the whole exercise to last? At what point should we start seeing tangible results of the mass-vaccination campaign?

They also addressed the challenges of the anticipated emerging Vaccinated Society. How to fight the myths of vaccines and the superstitions about histories of human immunizations? What exactly is being done to grow robust local confidence in the science of vaccinations and the vaccines themselves? More significantly, how to square these campaigns vis-vis personal rights, moral/religious obligations?

What messages are being sent out in these regards and how are Batswana responding? What about issues of justice and equality? Will we get the necessary vaccines to everyone who wants them? What is being done to ensure no deserving person is left behind?

They also addressed issues of health data. To accomplish this mass-vaccination campaign and do everything right we need accurate and complete data. Poor data already makes it very hard to just cope with the disease. What is being done to improve data for the mass-vaccination campaign? How is this data being collected, aggregated and prepared for real life situation/applications throughout Botswana in the coming campaign?

We know in America, for example, general reporting and treatment of health data at the beginning of vaccinations was so poor, so chaotic and so scattered mainstream newspapers like The Atlantic, Washington Post and the New York Times had to step in, working very closely with civil society organizations, to rescue the situation. What data-related issues are still problematic in Botswana?

To be specific, what kind of Covid-19 data is being taken now to ready the whole country for an effective and efficient mass-vaccination program?

Batswana must be made aware that the  end part of vaccination will just mark the beginning of a long journey to health recovery and national redemption; that in many ways Covid-19 vaccination is just another step toward the many efforts in abeyance to fight this health pandemic, the road ahead is still long and painful.

For this purpose, and to highlight the significance of this observation we tasked our panellists with  the arduous imperative of  analysing the impact of mass-vaccination on society and the economy alongside the pressing issues of post-Covid-19 national health surveillance and rehabilitation programs.

Research suggests the aftermath of Covid-19 vaccination is going to be just as difficult and uncertain world as the present reality in many ways, and that caution should prevail over celebration, at least for a long time. The disease itself is projected to linger around for some time after all these mass-vaccination campaigns unless an effort is made to vaccinate everyone to the last reported case, every nation succeeds beyond herd immunity, and cure is found for Covid-19 disease. Many people are going to continue in need of medications, psychological and psychiatric services and therapy.

Is Botswana ready for this long holdout? If not, what path should we take going into the future? The Second concern is , are we going to have a single, trusted national agency charged with the  mandate to set standards for our national health data system, now that we know how real bad pandemics can be, and the value of data in quickly responding to them and mitigating impact? Finally, what is being done to curate a short history of this pandemic? A national museum of health and medicine or a Public Health Institute  in Botswana is overdue.

If we are to create strong sets of data policies and data quality standards for fighting future health pandemics it is critical that they find ideological and moral foundations in the artistic imagery and photography of the present human experience…context is essential to fighting such diseases, and to be prepared we must learn from every tragic health incident.

Our panellists answered most of these questions with distinguished intellectual clarity. We wish Batswana to join us in our second Mass-vaccination workshop.

*Oscar Motsumi: Email:oscar.motsumi@gmail.com

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The women you see in the news matter. Here’s why

9th March 2021
Jane Godia

Jane Godia

Today is International Women’s Day – it’s a moment to think about how much better our news diet could be if inequities were eliminated. In 1995, when the curtains fell in one of the largest meetings that have ever brought women together to discuss women in development, it was noted that women and media remain key to development.

Twenty-six years later, the relevant “Article J” of the Beijing Platform for Action, remains unfulfilled. Its two strategic objectives with regard to Women and Media have not been met. They are
Increase the participation and access of women to expression and decision-making in and through the media and new technologies of communication

Promote a balanced and non-stereotyped portrayal of women in the media.

Today, as we mark International Women’s Day, it’s an indictment on both media owners and civil society that women remain on the periphery of news-making. They cannot claim equal space in either the structures of newsrooms or in the content produced, be that as sources of news or as the subjects of reports. Indeed, the latest figures from WAN-IFRA’s Women in News Programme show just one in five voices in news belong to women*, be they as sources, as the author or as the main character of the news report.

Some progress was evident several years back, with stand-out women being named as chief executive officers, editors in chief, managing editors and executive editors. But these gains appear short lived in most media organisations. Excitement has turned to frustration as one-step forward has been replaced with three steps backwards. In Africa, the problem is acute. The decision-making tables of media organisations remain deprived of women and where there are women, they are surrounded by men.

Few women have followed in the footsteps of Esther Kamweru, the first woman managing editor in Kenya, and indeed sub-Saharan Africa. Today’s standout women editors include Pamela Makotsi-Sittoni (Nation Media Group, Kenya), Barbara Kaija (New Vision, Uganda), Mary Mbewe (Daily Nation, Zambia), Margaret Vuchiri (The Monitor, Uganda), Joyce Shebe (Clouds, Tanzania), Tryphinah Dongwana (Weekend Post, Botswana), Joyce Mhaville (Independent Television -ITV, Tanzania) and Tuma Abdallah (Standard Newspapers,Tanzania). But they remain an exception.

The lack of balance between women and men at the table of decision making has a rollback effect on the content that is produced. A table dominated by men typically makes decisions that benefit men.

So today, International Women’s Day is a grim reminder that things are not rosy in the news business. Achieving gender balance in news and in the structure of media organisations remains a challenge. Unmet, it sees more than half of the population in our countries suffer the consequences of bias, discrimination and sexism.

The business of ignoring the other half of the population can no longer be treated as normal. It’s time that media leaders grasp the challenge, not only because it is the right thing to do, but because it also makes a whole lot of business sense: start covering women, give them space and a voice in news-making and propel them to all levels of decision making within your organisation.

We can no longer afford to imagine that it’s only men who make and sell the news and bring in the shillings to fund the media business. Women too are worthy newsmakers. In all of our societies, there are women holding decision making positions and who are now experts in once male-only domains such as engineers, doctors, scientists and researchers.

They can be deliberately picked out to share their perspectives and expertise and bring balance to the profile of experts quoted on our news pages. Media is the prism through which society sees itself and women are an untapped audience. So, as we celebrate International Women’s Day, let us embrace diversity, which yields better news content and business products, and in so doing eliminate sexism. We know that actions and attitudes that discriminate against people based on their gender is bad for business.

As media, the challenge is ours. We need to consciously embrace and reach the commitments made 26 years ago when the Beijing Platform for Action was signed globally. As the news consuming public, you have a role to play too. Hold your news organization to account and make sure they deliver balanced news that reflects the voices of all of society.

Jane Godia is a gender development and media expert who serves as the Africa Director of Women in News programme.  
WOMEN IN NEWS is WAN-IFRA’s ground-breaking programme to increase women’s leadership and voices in the news. It does so by equipping women journalists and editors with the skills, strategies, and support networks to take on greater leadership positions within their media. www.womeninnews.org

Jane Godia, Director, Africa, Women in News

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Why is the media so afraid to talk about sexual harassment?

9th March 2021

MELANIE WALKER

The eve of International Women’s Day presents an opportunity for us to think about gender equality and the long and often frustrating march toward societies that are truly equal.

As media, we are uniquely placed to drive forward this reflection and discussion. But while focusing on the challenges of gender in society, we owe it to our staff and the communities we serve to also take a hard look at the obstacles within our own organisations.

I’m talking specifically about the scourge of sexual harassment. It’s likely to have happened in your newsroom. It has likely happened to a member of your team. It happens to all genders but is disproportionately directed at women. It happens in every industry, regardless of country, culture or context. This is because sexual harassment is driven by power, not sex. Wherever you have imbalances in power, you have individuals who are at risk of sexual harassment, and those who abuse this power.

I’ve been sexually harassed. The many journalists and editors, friends and family members who I have spoken to over the years on this subject have also been harassed. Yet it is still hard for leaders to recognize that this could be happening within their newsrooms and boardrooms. Why does it continue to be such a taboo?

Counting the cost of sexual harassment

Sexual harassment is, simply put, bad for business. It can harm your corporate reputation. It is a drain on the productivity of staff and managers. Maintaining and building trust in your brand is an absolute imperative for media organisations globally. If and when a case gets out of control or is badly handled – this can directly impact your bottom line.

It is for this reason that WAN-IFRA Women in News has put eliminating sexual harassment as a top priority in our work around gender equality in the media sector. This might seem at odds with the current climate where social interactions are fewer and remote work scenarios are in place in many newsrooms and businesses. But one only needs to tune into the news to know that the abuse of power, manifested as verbal, physical or online harassment, is alive and well.

Preliminary results from an ongoing Women in News research study into the issue of sexual harassment polling hundreds of journalists in Sub-Saharan Africa and Southeast Asia indicate that more than 1 in 3 women media professionals have been physically harassed, and just under 50% have been verbally harassed. Just over 15% of men in African newsrooms reported being physically harassed, and slightly less than 1 in 4 reports being verbally harassed. The numbers for male media professionals in Southeast Asia are slightly higher than a quarter on both forms of harassment.

The first step in confronting sexual harassment is to talk about it. We need to strip away the stigma and discomfort around having open conversations about what sexual harassment is and isn’t. Media managers, it is entirely in your power to create dynamics in your own teams that are free from sexual harassment.

Publishers and CEOs, you set the organisational culture in your media company.

By being vocal in recognising that it happens everywhere, and communicating to your employees that you will not tolerate sexual harassment of any kind, you send a powerful message to your teams, and publicly. With these actions, you will help us overcome the legacy of silence around this topic, and in doing so take an important first step to create media environments that truly embrace equality.

Melanie Walker is Executive Director of Media Development of the World Association of News Publishers (WAN-IFRA). She is a creator of Women in News, WAN-IFRA’s ground-breaking programme to increase women’s leadership and voices in the news. It does so by equipping women journalists and editors with the skills, strategies, and support networks to take on greater leadership positions within their media. www.womeninnews.org

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