In 2000, in response to one of the greatest health challenges of our time, in a country disproportionately affected by HIV/AIDS, the government of Botswana, The Merck Company Foundation/Merck, and the Bill & Melinda Gates Foundation established the African Comprehensive HIV/AIDS Partnerships (ACHAP).

ACHAP's mission is to support and enhance Botswana's response to the HIV/AIDS epidemic through a comprehensive approach that includes HIV/AIDS prevention, treatment, care and support, and impact mitigation. At its inception, The Merck Company Foundation and the Gates Foundation committed $106.5 million to the partnership, and Merck agreed to donate its antiretroviral (ARV) medicines—STOCRIN^® (efavirenz) and CRIXIVAN^® (indinavir sulfate)—to Botswana's national antiretroviral (ARV) treatment program—known as Masa (or "new dawn")—for the partnership's duration. In November 2008, Merck expanded its donations to include ATRIPLA^® (efavirenz 600 mg/emtricitabine 200 mg, tenofovir disoproxil fumarate 300 mg) and ISENTRESS^® (raltegravir).

In 2010, The Merck Company Foundation committed an additional $30 million over five years (2010-2014) to support Phase II of ACHAP. Through this additional $30 million, five-year grant, matched by the Gates Foundation, ACHAP will be able to build on the progress of its first ten years of operation. It will initiate a multipronged effort to scale up HIV-prevention programs with a particular focus on providing safe male circumcision for young men and boys aged 15-29 and a package of prevention interventions focused on young women and girls; efforts to continue increasing access to, and utilization of, HIV counseling and testing services; and support for the integration of HIV and TB services nationally. During Phase II, ACHAP will work to continue to transition the programs to the government of Botswana and other local organizations and to initiate a comprehensive communications strategy to leverage the achievements and lessons learned.

The partners selected Botswana because it had one of the highest adult prevalence rates of HIV/AIDS in the world (see sidebar below), a viable existing healthcare infrastructure, and strong political will and commitment to address the challenges of HIV/AIDS.

From the beginning, Merck and the Gates Foundation sought to create a program that would leverage private-sector management expertise to resolve social and public health issues. They also hoped to create a pilot program, which, if successful, could serve as a model to inform and encourage others in government, international organizations, foundations and the private sector working to address HIV/AIDS in other countries or regions.

Lessons Learned in Botswana

• A successful national response to HIV/AIDS requires sound, enabling policy to drive and guide the right course of action
• Local, national and international partners must integrate and align all efforts to the national blueprint
• Success depends on building local capacity and achieving buy-in at all levels
• It is possible to implement effective antiretroviral therapy, even in a resource-limited setting
• A sustainable solution must address both treatment and prevention
• ACHAP is considered an important model to address the African HIV epidemic, and lessons learned can be leveraged to inform positive action in other countries in the region
• Working collaboratively and in a complementary fashion with other development partners has enabled the expansion and strengthening of key programs

Looking Ahead

While much progress has been made in Botswana, particularly in the area of treatment, expansion of HIV counseling and testing services (HCT), and improving ACHAP's institutional capacity to deliver effectively on its strategic objectives, much still needs to be done as part of a comprehensive, sustainable and successful response to the AIDS pandemic in that country. It is becoming increasingly apparent that if Botswana is to get ahead of this epidemic, the focus needs to be on prevention.

In addition, ACHAP recognizes the need to build greater capacity among local organizations, increasing the capacity of communities to utilize and provide HIV/AIDS services. Therefore, priorities for ACHAP going forward will include the scaling-up of prevention efforts, addressing the needs of patients coinfected with TB, improving the cost effectiveness of the Masa antiretroviral treatment program, and strengthening the capacity of local organizations for a sustainable national response. The ultimate goal is for the efforts and programs ACHAP supports to become either self-sustaining or integrated into the efforts led by the Government of Botswana.

A Daunting Task

When ACHAP was established in 2000, more than one in four adults was infected with HIV in Botswana–then the highest HIV prevalence rate in the world. HIV prevalence exceeded 30 percent among men and women in the 25–40 age group. More than one-third of children born to HIV-positive women became infected with the disease. The number of AIDS orphans had quadrupled in five years. Fewer than five percent of those in need of antiretroviral (ARV) therapy were receiving it, and health facilities were overburdened: Patients who were HIV-infected and in need of care occupied about 60 percent of hospital beds. There was a severe shortage of health workers and physicians, particularly those trained in the area of HIV/AIDS. Life expectancy at birth had declined by 13 years, and between 1991 and 2003, morbidity had increased fourfold among 25-44 year olds. At this rate, the total population of the country was expected to be reduced by 18 percent, while the gross domestic product was projected to decline 4.5 percent annually, resulting in an economy 30 percent smaller than it would have been without the impact of AIDS.