Botswana's government has warned that it may have to cut or completely withdraw its HIV/AIDS funding, despite the rising number of people needing treatment, as the global economic crisis takes a toll on the vitally important diamond-mining sector.
The government is the main financier of the national HIV/AIDS response, contributing up to 80 percent of the budget, with donors making up the remainder. But the global economic slump has led to significant declines in the sale of diamonds, Botswana's most important revenue source.
There are already indications that government HIV/AIDS funding may dry up after the latest National Strategic Framework (NSF) – to be launched next month - expires in 2016.
The national HIV response is guided by the NSF, which is developed by the government in consultation with the private sector, civil society and donors, and is renewed every four years.
"The budget we have now is not going to sustain us beyond 2016," Robson Dimbungu, chief programme planning officer of the National AIDS Coordinating Agency (NACA) told a meeting in Gaborone, the capital, this week to preview the new NSF. "If we do not do something about our revenues, we are going to find ourselves in a tough situation."
Botswana has used its mineral wealth to roll out an antiretroviral (ARV) programme that has been the envy of other countries in the region. By the end of September 2008, public health facilities were providing ARV treatment to 90,921 patients, which, together with the 22,000 people accessing medication in the private sector, represents about 94 percent of those in need of the life-prolonging drugs, according to UNAIDS estimates.
Significant declines in diamond sales have already been recorded and more are expected, according to the Minister of Finance and Development Planning, Baledzi Gaolathe. In his recent 2009/10 budget address, Gaolathe projected that revenue from diamond sales would decline by about 50 percent.
With the government's income dwindling, Dimbungu said there was an urgent need to scale up efforts to prevent further infections. "The bottom line is that we really need to change our behaviour. For those who are going to be infected after 2016, I think it is going to be very tough for them," he said, adding that measures would be put in place to ensure that those already on ARV treatment could continue receiving it.
Peter Stegman, a strategic planning and policy development consultant to the African Comprehensive HIV/AIDS Partnerships (ACHAP), a public-private partnership between the Botswana government, the Bill & Melinda Gates Foundation, and pharmaceutical company Merck & Co. Inc, agreed that the likely funding cuts would shift the focus to behaviour change.
"The more infections we prevent, the fewer the people who will need treatment," he said. "There is a lot to be done in terms of looking at alternative directions."
Even before the extent of the economic crisis became apparent, President Ian Khama warned that the government could not shoulder the cost of a continually expanding ARV treatment programme indefinitely. Speaking at a World AIDS Day event in December 2008, he noted that if patients were enrolled in the programme at the current rate it would nearly double in size by 2016.
Lydia Mafhoko-Ditsa, the HIV/AIDS programme manager at the United Nations Development Programme (UNDP) in Botswana, suggested that a potential solution to a future funding shortfall might be to follow the example of Zimbabwe and Zambia: both countries have introduced an AIDS levy that channels a certain percentage of taxes into the national HIV/AIDS response.
"How can we also come up with innovative and sustainable programmes?" she asked at this week's meeting. She proposed partnering with other countries in the region to manufacture generic ARVs as one cost-saving measure, and said more research was needed into the cost implications of Botswana's treatment programme over the next five, 10 and 20 years.
Botswana has an adult HIV prevalence rate of 23.9 percent, the second highest in the world, but Mafhoko-Ditsa urged people not to dwell on these gloomy figures.
"For me the bone of contention is not the statistics, but what we should do to get to a better position; numbers will not help us in fighting this epidemic."