GABORONE, Botswana — Catherine had already buried two sisters because of AIDS when she was diagnosed with the dreaded disease. After doctors broke the news, she stopped eating. "I thought that was the end of my life," she said.
Three years later, the bubbly young woman in a floppy sun hat is sharing her marriage plans with fellow patients as they wait for medicines that are bringing new life to one of the countries worst-hit by AIDS.
In 2002, Botswana became the first African country to offer free treatment to all who needed it. With more than a third of adults infected, many doubted it could fulfill the promise.
But the largely desert nation now has half the estimated 110,000 people in immediate need on life-prolonging anti-retroviral medicines, showing that treatment is possible on the world's poorest continent.
"If HIV was left to take its course, this country would be literally destroyed both economically and socially," said Segolame Ramotlhwa, operations manager for the national treatment program dubbed Masa, or New Dawn. "Not treating is not an option."
AIDS has ripped through sub-Saharan Africa, killing 2.4 million people this year alone, according to U.N. figures. In Botswana, life expectancy has plunged to 39 years, AIDS patients overwhelm hospital wards and funeral homes offer 24-hour service.
Medicines that have turned the disease into a manageable chronic condition in wealthier nations remain out of reach for most in Africa, home to more than 60 percent of the estimated 40 million people globally infected with HIV, the virus that causes AIDS. The cost is prohibitive and few countries have the infrastructure to dispense them on a large scale.
Commitment to fight
Botswana, which is slightly smaller than Texas, has the advantage of a small population of 1.7 million. Diamonds have made the country comparatively wealthy, and most people live within five miles of a clinic.
But Health Minister Sheila Tlou says the most important difference is Botswana's commitment to fight the pandemic. Its pledge to provide treatment drew critical support from donors such as the Bill & Melinda Gates Foundation and major pharmaceutical companies, but the government is paying more than 90 percent of the cost itself.
"African countries say they have no money, but if a war is brewing, in the blink of an eye, that money would be there," Tlou said. "So you need that commitment. Instead of spending money on Cadillacs, put money where the people are."
The massive treatment effort is straining limited resources, though. Development funds have been diverted to health, which accounts for a quarter of the national budget.
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Some 52,000 patients are being treated free at 32 sites nationwide, while 7,300 others obtain their medicines privately.
The results are visible. Patients who once arrived in wheelchairs and on stretchers now walk to clinics. Others believed to be on their deathbeds are back at work.
The treatment is complicated, and missed doses can cause resistance to build. But churches and other groups help ensure patients have a "buddy" to support them, and doctors say the rate of adherence tops 85 percent.
The availability of treatment also is encouraging more people to get tested on a continent where stigma remains high.
Catherine was rail-thin and covered in sores, but she waited two years to find out if she had the virus that killed her siblings.
"That time there was no treatment, so I didn't want to check," said the mother of two, still too ashamed to give her last name. "There were many funerals because of this disease."
Authorities estimate that up to 35 percent of those infected here now know their status, far higher than in other countries.
Understanding of the disease also is spreading. Patients once locked in silence now chat openly with each other in waiting rooms, swapping details of their CD4 counts and viral loads.
But fear, ignorance and denial still keep many away until it is too late. Catherine's fiance reminds her to take her pills but refuses to be tested himself.
When Cynthia Leshoma was first given anti-retrovirals, she was so depressed she swallowed all the medicine at once and washed it down with cleaning fluid.
When she emerged from a coma three days later, she decided to turn her life around. She quit drinking, joined a support group and learned to take her medicine. Earlier this year, she was crowned Miss HIV Stigma Free in a beauty pageant that aims to change attitudes about the disease.
"In Botswana, we are lucky because the government is offering us medicine," said Leshoma, counting out pills on a restaurant table after her cell phone tells her it is time. "People die because of stigma, not because of AIDS."
Hoping to get more people on treatment, Botswana started routinely offering HIV tests throughout the health system in 2003. Now, so many patients agree to get tested that doctors worry whether they will be able to keep up with demand.
More than 12,500 people are being treated at Princess Marina Hospital in the capital, Gaborone, a dry, flat city full of strip malls. Patients line up before dawn for the daylong wait to collect monthly supplies of medicine.
"If everybody who needs treatment suddenly turned up, then we wouldn't cope," said Dr. Howard Moffat, the medical superintendent.
He also said success has some downsides. Patients may not adhere to treatment plans once they start feeling better, and the infection rate could climb even higher because treatment will reduce fear of the disease.
"Botswana has shown what can be done," Moffat said. "But it will need help for a considerable time to come."
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