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SAMJ: South African Medical Journal

On-line version ISSN 2078-5135
Print version ISSN 0256-9574

SAMJ, S. Afr. med. j. vol.104 n.5 Cape Town May. 2014




'It would have been better if I had HIV instead of diabetes'



To the Editor: 'Go ka bo go ne go le botoka go nna le HIV gona le bolwetse jwa sukiri' ('It would have been better if I had HIV instead of diabetes'). This flippant comment was overheard in a diabetes clinic waiting room in southern Botswana earlier this year. Although a new diagnosis of diabetes does not carry the stigma of a new HIV diagnosis, for many patients it nonetheless feels like a life sentence. While there are no local data to support the suggestion that type 2 diabetes mellitus (T2DM) confers a worse prognosis than HIV, patients with T2DM in Botswana face at least as many obstacles to high-quality care as do patients with HIV.

A network of HIV counselling and testing facilities means that access to free, anonymous, same-day HIV testing is available throughout Botswana.^ Despite an estimated prevalence of approximately 11%,[2] screening for diabetes is not routinised and most diagnoses are made when patients present late in the course of their disease. While 97% of Batswana adults have been tested for HIV in the past 12 months,[3] more than 80% of patients with T2DM are unaware that they have it.[2]

Notably, there are also stark contrasts in the competence of clinicians to manage these diseases. The Ministry of Health has had considerable success in building capacity to deliver HIV care across the country.[4] Many nurses and doctors are now capable of initiating and managing patients on antiretrovirals. In contrast, many healthcare providers lack confidence in managing patients with advancing diabetes, especially those on insulin therapy. That only two oral medications (metformin and glibenclamide) and three insulin formulations (Actrapid, Actraphane and Protophane) are available on the national formulary also illustrates how T2DM remains under-prioritised at a policy level.

Disparities in how disease-specific complications are managed are also striking. While most HIV-infected patients are screened for renal dysfunction and hepatitis before ART initiation and regularly thereafter, screening for DM complications occurs far less frequently. Furthermore, the diagnostic infrastructure to screen for diabetic nephropathy and retinopathy is largely unavailable outside Gaborone.

The rapid increase in the incidence of diabetes in Botswana is cause for alarm,[5] as is the marked lack of clinical capacity to manage patients who develop this complex, chronic condition. Botswana has had significant success in responding to the HIV epidemic: in excess of 90% of eligible individuals are now on antiretrovirals. Lessons learnt from this success - leveraging HIV screening strategies and capacity building initiatives - are necessary to improve outcomes for patients living with T2DM in Botswana.


M J A Reid

Botswana UPenn Partnership, Botswana; Perelman School of Medicine, University of Pennsylvania, USA; School of Medicine, University of Botswana

B Tsima

School of Medicine, University of Botswana


1. Creek TL, Alwano MG, Molosiwa RR, et al. Botswana's Tebelopele voluntary HIV counseling and testing network: Use and client risk factors for HIV infection, 2000-2004. J Acquir Immune Defic Syndr 2006;43(2):210-218. []        [ Links ]

2. Whiting DR, Guariguata L, Weil C, Shaw J. IDF diabetes atlas: Global estimates of the prevalence of diabetes for 2011 and 2030. Diabetes Res Clin Pract 2011;94(3):311-321. []        [ Links ]

3. National AIDS Coordinating Agency. Preliminary Results Botswana AIDS Impact Survey IV Gaborone: Statistics Botswana, 2013:25.         [ Links ]

4. Bussmann C, Rotz P, Ndwapi N, et al. Strengthening healthcare capacity through a responsive, country-specific, training standard: The KITSO AIDS training programs support of Botswana's national antiretroviral therapy rollout. Open AIDS J 2008;2:10-16. []        [ Links ]

5. Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes: Estimates for the year 2000 and projections for 2030. Diabetes Care 2004;27(5):1047-1053. []        [ Links ]

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