Botswana's Gains Against AIDS Put U.S. Claims to Test

In Botswana, a landlocked nation of 1.6 million people in southern Africa, officials were tackling one the world's worst AIDS epidemics. Nearly four of every 10 working-age adults were infected with HIV, the virus that causes the disease. Bolstered by vast diamond wealth and a stable government, President Festus Mogae had committed the nation to providing costly, state-of-the-art AIDS treatment to every citizen.

The daring promise, the first of its kind in Africa, attracted tens of millions of dollars in support from donors, including substantial amounts from the U.S. government, which took the lead in upgrading laboratories and building a network of centers to test patients for HIV.

With the inception of the Bush program, both the White House and Congress began focusing on delivering the antiretroviral drugs that alone had the prospect of saving millions of lives. And the U.S. officials charged with implementing this vision were also supposed to produce quantifiable results to make explicit the value of the $15 billion investment.

In Botswana at least, deciding who deserved credit for any one person getting the drugs proved complicated.

Harriet M. Isaacs, a 59-year-old civil servant with AIDS, started taking antiretrovirals in 2002, the year before Bush announced his program. The drugs have restored her to health, and with a few months left until her planned retirement, she now looks forward to many more years of playing with her grandchildren.

She expresses no doubt about who saved her life: the government of Botswana.

"It's very expensive," Isaacs said while seated in a bustling AIDS clinic here, "but it's helping people. . . . I'm confident that I can go up to 100 [years old] now."

The reality of who paid for her health care is more complex. She visits a clinic built with the help of the Bill & Melinda Gates Foundation. She takes medicine donated, in part, by the American pharmaceutical giant Merck. And the cost of most everything else -- doctors, nurses, lab work -- is covered by the government of Botswana.

For Isaacs, the role played by the Bush program -- so far, at least -- has been minor, confined mainly to the training of medical personnel and the monitoring and evaluation of the existing government program. The total outlay of U.S. government funds for "treatment" in Botswana last year was $2.5 million, about one-twentieth of the amount paid by the Botswana government. And even that money was delayed by many months.

Yet when it came time to tabulate the Bush program's successes in Botswana, every patient receiving antiretroviral drugs from the national program, including Isaacs, was included. U.S. officials also counted several thousand others who were receiving their medicine from private doctors because, Kilmarx said, some had benefited from a U.S.-funded training program.

He explained that since the January news release in Davos, the number of AIDS patients for which the Bush administration was claiming credit had continued to grow. That day, he said, he was submitting a new total of 41,444 in Botswana to top program officials in Washington. Everyone in Botswana receiving antiretroviral drugs was included, Kilmarx said.

In the days that followed, Kilmarx was asked about the comments made by Mazonde, Ramotlhwa and other health officials from Botswana. He defended the program and then called another meeting with them. Later on the day of that meeting, he reiterated his defense of the numbers, saying that Mazonde and Ramotlhwa were "entirely comfortable" with how the Bush program had portrayed its role in Botswana.