Historical Background
As early in its epidemic curve as 1987 the Government of Botswana developed a Short Term Plan in response to the HIV/AIDS situation. This was followed by the Me-dium Term Plan for the period 1989 to 1993. This document has continued to provide policy and strategic guidance since the inception of the National Aids Control Pro-gramme. In November 1993, the government launched its National Policy on HIV/AIDS. This was subsequently revised and the revised policy was approved and adopted by government through presidential directive CAB:33/98 dated September 1998. The president of Botswana, His Excellency Mr. Mogae, personally chairs the gov-ernment's highest advisory body on the epidemic, the National Aids Council. It is housed in the Ministry of Health. In October 2000, the National Aids Co-ordinating Agency (NACA) was established. This is a multi-sectoral body charged with facilitating, monitoring and evaluating the national response to HIV/AIDS. Concurrently intensi-fied information, education and communication campaigns against HIV/AIDS were launched to target all sectors of the society.
The national policy on HIV/AIDS prevention and care outlines the national re-sponse to the epidemic(Republic of Botswana 1998). It describes the role of national leaders, various government ministries, the private sector, non-governmental (NGOs) and community-based (CBOs) organisations, persons living with HIV/AIDS, and indi-vidual community members, in the national response. It goes on to outline in detail the role of each of the relevant government ministry/department, private sector, NGOs and CBOs. It also details aspects covering HIV testing, confidentiality, HIV/AIDS and employment.
The policy formed the basis on which a national strategic plan would be developed.
Within the national strategic plan, different ministries and organisations would formu-late their sectoral plans and projects for implementation.
The policy has been adopted as a code to be observed by all stakeholders (including employers in the private sector). Legislation would be developed as the need arises to support implementation and compliance.
National Policy on HIV/AIDS and employment (role of private sector).
The national policy on HIV/AIDS is very clear on the roles to be played by each and every relevant ministry/organisation in the multi-sectoral response to the epidemic.
With regards to HIV/AIDS at the workplace, the role of the Ministry of Labour, Home Affairs and Social Welfare is:
• To develop legislation regarding the rights of HIV-infected individuals to em-ployment, social welfare and compensation where relevant.
• To ensure, through the Labour Department, that the rights of workers with HIV/AIDS are not infringed, as stipulated in the policy and any labour-related legislation that may be developed.
The role of the Private Sector Organisations and Enterprises is:
• To develop and implement policies and programmes for the management of HIV/AIDS, in line with the national policy guidelines. These will include the implementation of HIV/AIDS and STD prevention, education for workers, condom distribution, as well as protection of the rights of HIV-infected workers.
• To mobilise local private sector financial and other resources for HIV/AIDS education of workers and related communities.
• To integrate HIV/AIDS into training courses for workers and managers where appropriate.
• To mobilise the local private sector to provide resources for Community Home Based Care (CHBC) for their workers and related communities.
The Botswana Confederation of Commerce, Industry & Manpower (BOCCIM) and the Botswana Federation of Trade Unions (BFTU) will play leading roles in mobilising private sector organisations and workers for HIV/AIDS prevention and care in the country.
• HIV testing should not be carried out as part of periodic medical examination of employees
• Information about the HIV status of individuals should be treated confiden-tially, and not be divulged to others without the consent of the person con-cerned.
The “principle of shared confidentiality” should be applied. This means that those who it is deemed "need to know" another person's status in order for appropriate health and social welfare care to be provided should be told. Family members should be in-volved from the outset in the management of persons with HIV/AIDS preferably with their consent. Health and social services providers should make all efforts to involve family members in the pre-test phase.
There should be no obligation for the employee to inform the employer regarding his/her HIV/AIDS status. However, where the employee feels that sharing such infor-mation with a supervisor or employer would be helpful, health and social services pro-viders should assist the employee.
The lives of many young and middle-aged adults are spent at the workplace. The employer (government, private sector and parastatal organisations) will have to manage staff affected by HIV/AIDS and make decisions regarding recruitment, training, pay-ment of terminal benefits, and retirepay-ment due to ill health, amongst many other issues.
The National HIV/AIDS policy directs the following:
• Workers with HIV infection who are healthy should be treated the same as any other worker, with regard, for example, to training and promotion. Being infected with HIV should not be a reason for an individual being declared unfit for employment, or for dismissal from employment.
• Workers with HIV-related illness and AIDS will be treated the same as any other worker with an illness. They should thus be retained in employment as long as they are medically fit to work.
• HIV-infected employees should have access to and receive standard social security and occupationally related benefits.
• Colleagues, employers, union and/or clients should protect persons with HIV/AIDS in workplaces against stigmatisation and discrimination. Organi-sations should include aspects of this protection in workplace education and information programmes.
• Employees should have access to information and educational programmes on HIV/AIDS and STD at the workplace, as well as to referral for appropri-ate counselling and medical care.
• Government should develop a prototype policy regarding HIV/AIDS and workers, consistent with the national policy. This policy should be communi-cated to all concerned, monitored for its implementation, evaluated for its
ef-fectiveness, and periodically reviewed in the light of emerging information about HIV/AIDS.
Implementation of the Botswana National HIV/AIDS Policy to date.
Overall, the policy’s implementation has been successful albeit with a lot of chal-lenges. Private sector employers and civil society organisations such as non-governmental organisations, Faith Based Organisations and Community Based Organi-sations are an integral part of the multi-sectoral response.
The government has created international links and formed effective working rela-tionships with development partners. In this respect it is working in close collaboration with international development partners, including the United Nations Children’s Fund, United Nations Development Programme, United Nations Population Fund, the World Health Organisation, the African Comprehensive HIV/AIDS Partnership, Botswana United States Partnership, United States Agency for International Development, Bot-swana-Harvard Partnership, Swedish International Development Agency, the Southern African Development Community, the Commonwealth and the European Union.
Some of the government’s achievements in partnership with its collaborators include the provision of antiretroviral therapy to the public at no cost (beginning at 4 central sites in 2002 due to institutional limitations), nation-wide prevention of mother-to-child transmission, the voluntary counselling and testing programme, the community home based care and the orphan and vulnerable children programme.
The national strategy and policy is supported by a comprehensive information man-agement system to monitor and evaluate progress in all modalities of the strategy, and the overall societal progress in combating the pandemic (Botswana HIV/AIDS Re-sponse Information Management System - BHRIMS). Indicators have been developed for each component of the national response, allowing progress to be mapped on a
va-In short, the national response to HIV/AIDS in Botswana is extremely well informed by the reality of the disease on the ground (Ministry of the State President, Botswana:
NACA 2003).
The challenges are as extreme as the arsenal of weapons accumulated in the national strategy, however. HIV prevalence using the annual sentinel survey of pregnant women in all the 22 Botswana health districts has been rising. In 1992 it was 18%, in 2000 it was 38.5%, reaching a plateau in 2001 of 36.2% and dropping to 35.4% in 2002. The epi-demic pattern has been generalised sparing no district. All districts except Ghantsi have an HIV prevalence exceeding 20%. On the whole the prevalence ranges from 18.8%
(Ghantsi) to 48.1% (Selebi Phikwe). Up to October 2002, 60% of all medical ward ad-missions were due to HIV-related conditions with some of the wards running at 95%
occupancy rates due to HIV/AIDS. Bed occupancy rate for most general medical wards is over 100% while occupancy rate for medical wards in major referral hospitals is over 133% (Ministry of State President, Botswana NACA 2002).
The national ARV programme is the first in Africa intending to offer universal ARV treatment to the estimated 330 000 people in Botswana living with HIV/AIDS out of a population of about 1,6 million. Uptake of the national ARV programme has however been slow. As at mid-January 2003 enrolment for the ARV therapy stood at only 4425 people, of whom 3515 had actually received treatment, and they were concentrated in Gaborone, with smaller numbers at the Francistown, Serowe, and Maun centres. Prob-lems be-setting this intervention are:
• getting word to rural areas while combating stigmas surrounding HIV/AIDS
• misinformation or lack of information concerning ARV therapy. This needs to be continued by informing people of the facts about HIV/AIDS mobiliz-ing them for treatment and explainmobiliz-ing the effects of the medication.
• Increase training at rural clinics to increase the number of ARV sites around the country, thus minimizing travelling distances of patients and also reaching a larger population of people living with HIV/AIDS. This should be done with urgency, because the current inaccessibility of ARV drugs to patients is a serious obstacle that not only hinders effective medical and psychosocial sup-port, but also makes some patients to loose hope in life altogether.
Implementation in the Botswana private sector -company and workplace programmes
By November 2002, some industrial and commercial undertakings as well as para-statals had taken the lead in responding to the epidemic by establishing workplace HIV/AIDS policies and programmes, some of them covering the whole spectrum of
prevention care and support. Debswana Diamond Company, Barclays and Standard Chartered Banks, Botswana Telecommunication Corporation and Botswana Power Corporation reported that they had developed and implemented response pro-grammes (Ministry of State President, Botswana 2003). Medical aid schemes also re-ported that they had implemented benefit packages for members in the private sector to cover treatment of opportunistic infections and anti-retroviral treatment for HIV.
The banking sector launched an exchange programme in 2002 to disseminate infor-mation between competitors in their sector about HIV strategies, to disseminate best practices and approaches to implementation, signalling that they were moving HIV/AIDS out of the area of competition. Nevertheless, even within the banking sector, there were considerable differences in the scale of the response: Barclays launched an antiretroviral treatment programme in 2002 for staff and their registered dependants subsequent to an un-linked anonymous testing amongst all staff members, and determined the burden of sickness related to HIV/AIDS amongst their workforce. These programmes were accompanied by awareness campaigns, distribu-tion of condoms in all branches, and training and placement of peer educators in all 54 branches. In contrast, First National Bank's programme in the same year was much more limited to a guidance and counselling service, run by a full time HIV/AIDS co-ordinator who has the responsibility of developing training programmes, and volun-teer peer educators.
BOCCIM was developing during 2002 a model corporate intervention strategy, using funding from the Global Business Coalition on HIV/AIDS. BOCCIM has approved the establishment of a private sector co-ordination unit on HIV/AIDS in its umbrella bodies in year 2000, which had a membership of 1600 by 2002. In that year, the unit commissioned a study of HIV/AIDS amongst migrant workers in Botswana.
From the workplace, cases are now surfacing through courts where employees are being dismissed because they have tested HIV positive. Issues of pre- and post-HIV/AIDS test counselling need enforcing. In the first week of June 2003, an Industrial Court judge vindicated a victim and ordered that he be compensated. In the judge’s ruling, however, the national policy on HIV/AIDS was dismissed as “having no force of law but only having a strong moral persuasive force not legally binding an employer as regards to recruitment decisions.”(Botswana Guardian 2003).
BHRIMS in Botswana has resolved that there is a need for better information on the private sector response, and developments in the workplace in general. The National Data Collection Plan of BHRIMS therefore includes a plan for workplace programme surveys in the years 2003 and 2005, to report in 2005 (Ministry of State President, Bot-swana NACA 2002). We hope our report "Crossing Borders to Fight HIV/AIDS" will assist in informing these surveys, and will provide a baseline information set for some of the areas where knowledge is presently limited.