Somehow, I thought it would be more romantic...

Growing up, I fantasized about having a canopy bed where I would sleep under a cascade of beautiful pink fabric. I didn't have any clue what the purpose of sleeping under a canopy of fabric might be, but is seemed very romantic-- and most princesses did it.

Later in life I learned that this cascade of fabric that I had seen floating above people's beds in pictures and movies was actually a mosquito net and it was used for keeping mosquitoes off the person sleeping under it. In fact, Jessie, mom and I used mosquito nets while we were in Costa Rica. This revelation and experience took some of the romanticism away from the whole idea, but they still seemed pretty exotic.

Well, yesterday I got my very own mosquito net-- treated with 'long-lasting insecticide'! For the record, needing a mosquito net is not romantic at all and having one isn't very fun either. I know I should not complain about having a mosquito net-- there are people dying of malaria because they don't have mosquito nets. But, I have to lament that my mosquito net is NOT pink, and it is a bit frightening to wake up and find that you are trapped under a net. Thankfully we don't have malaria in Gaborone, but we DO have mosquitoes-- and the rainy season hasn't even started. (yikes)

While my insecticide-treated net cost P315, you can purchase one for someone in need for only $6. The following link is to World Vision's Operation Safety Net:

http://www.worldvision.org/worldvision/eappeal.nsf/donation-item?open&amt=18&num=360&%3FOpen&go=item&item=1849059

Sugar daddies and small houses

This is the second installment in my series on HIV/ AIDS prevention strategies. This time, I am writing about messages targeting multiple concurrent partnerships and a few miss-steps in messaging about this sensitive topic. Part of the Mochudi Prevention Project is to support existing, effective prevention messages.

Media messages play an essential role in educating the public. Accordingly, health and social organizations in Botswana have employed multiple media resources including radio, television, billboards and pamphlets to get messages about HIV/ AIDS to the masses. One of the greatest challenges to effective 'messaging' is articulating and disseminating the right message to the right people at the right time.

There is currently a media campaign targeting multiple concurrent partnerships (MCP's). It is common for people in Botswana to have multiple concurrent sexual partnerships (NACA defines this as having two or more sexual partners at the same time) and this has contributed to the high rates of HIV/ AIDS in the country. Hopefully, this campaign will get the right message, to the right people at the right time and promote safer sexual practices.

Media messages need to be delivered using appropriate and relevant language. This can often be difficult to achieve- especially in a country where there are two common languages (Setswana and English).

However, not all messages are interpreted as they were intended. Here is an example of a misinterpretation of slang and an example of a seemingly universally accepted slang term:

An example of a miss-step in messaging in Botswana was the use of the slang term 'small house.' There was an HIV prevention message saying something like, "Small houses contribute to HIV transmission"

In the local culture, a 'small house' is where a man goes outside of his primary household/ partnership for sex. Logically, these multiple concurrent partnerships increased HIV and other STI transmissions. However, 'small house' also refers to a literally 'small' house. This difference in meanings lead some to miss-interpret the message to meaning that having or living in a small house increased HIV transmission.

An example of the use of a slang term that seems to cross cultural lines is the term 'sugar daddy.' Sometimes a woman will have different sexual partners to meet different needs- sometimes those needs are financial. The term 'sugar daddy' for someone who you have sex with who in turn supports you financially or buys you gifts seems to be a universal term.

Botswana's Vision 2016 & the Mochudi Prevention Project

The year 2016 will mark the 50th anniversary of Botswana's independence.
In anticipation of this milestone, various stakeholders came together in
the 1990's and developed the Vision 2016 Strategic Goals. These Goals
cover everything from health and education to security, morality, and
culture.

The Mochudi Prevention Project addresses the HIV/ AIDS section of Vision
Pillar 6: A Compassionate, Just and Caring Nation that reads, “By the year
2016, the spread of the HIV virus that causes AIDS will have been stopped,
so that there will be no new infections by the virus in that year.”
(http://www.vision2016.co.bw/index.html)

Since the establishment of the Vision 2016 Strategic Goals, researchers
and policy makers have made great strides in HIV/ AIDS treatment; however,
the prevalence of HIV in Botswana has continued to climb. Currently
available treatments have been very successful in Botswana, but treatment
alone is not a sustainable model. In order for Botswana to realize the
goal of zero new infections by 2016, new and effective prevention
strategies are essential.

This is what I think is so exciting about the work we are doing in the Mochudi Prevention Project-- we are using a comprehensive approach to transmission prevention. I am specifically interested in interventions that target behavioral change including: promoting the ABC's (abstinence, being faithful and condom use), encouraging people to get tested and emphasizing the importance of infant and adult (for HIV negative males) getting circumcised.

So, I thought I would highlight a few of the prevention strategies that
are currently underway in Botswana (and at BHP). This week's highlighted prevention
strategy is infant circumcision.

As you likely know, circumcision can help prevent an HIV negative male
from becoming HIV positive. In response to this evidence, several of my
colleagues have been involved in acceptability and implementation studies
about infant circumcision in Botswana. This week I had the opportunity to
observe a newborn circumcision in their clinic. The procedure they used
was like nothing I had ever seen (and I've seen a lot of infant
circumcisions). The Accu-Circ is really amazing- and apparently it holds
great promise for scaling up the infant circumcision efforts in Botswana-
which is a very good thing.

Coming soon, I will blog about media messages including abstinence, condom
use and discouraging multiple concurrent sexual partnerships (such as
sugar daddies and 'small houses.')

In closing, next weekend, the nation will be celebrating Independence Day and her 44th birthday (complete with a 4-day weekend). That leaves six
years for her to realize the Vision 2016 Goals. The team at BHP are certainly doing their part to give Botswana her best shot at realizing the HIV-related Vision 2016 goals. Oorah!

p.s. the image included in this posting is from the US Embassy- Botswana Facebook page

Morning at Mokolodi

This morning I went to the Mokolodi Nature Reserve- which is just south of Gaborone. I caught a ride to the Reserve with a friend who was attending a meeting there. While he and many of our colleagues were attending a strategic planning meeting at the Mokolodi Conference Center, I went on a game drive and enjoyed the education center, gift shop and grounds. When I arrived for my 0730 drive, the woman at the registration desk informed me that I was the only person who had signed up for the drive and they needed a minimum of 2 people. So, I was going to have to pay for 2 people if I wanted to go… unless, I wanted to go on the ‘game drive + cheetah visit.’ There wasn’t anyone signed up for the ‘game drive + cheetah visit’ either, but at 295 Pula, they didn’t make ‘solos’ pay double. So, I fell for the up-sell and went on the ‘game drive + cheetah visit.’

The Mokoldi Nature Reserve is essentially just some protected property that has rudimentary dirt roads through it (think a lot of bouncing in the back of a truck) and it is home to several types of truly wild animals… that is, except for a pair of tame cheetahs who were abandoned early in life and now live in a large fenced area within the Reserve. There are also some young spotted hyenas who are in a large enclosure who were abandoned, but they are not tame.

My 2+ hour, solo drive through the Reserve, accompanied by two guides, was very successful. I saw impalas, white rhinos, giraffes (my favorite), roans (the largest antelope in Africa), ostriches, monkeys, and lots of beautiful birds. I also learned about ecology and conservation in Botswana and Africa.

But, the best part of all, was visiting the cheetahs! We found Duma (the darker one)
and Letotse (the lighter one) around 0945 lounging in the shade purring audibly. As the only guest on the visit, I got to pet them and ask questions while my photographer-guides snapped pictures of us.

So, the moral of the story is that when things don’t work out as planned, they sometimes work out even better. And, while I was trying to experience Africa’s wilderness in the ‘born-free, live free’ spirit, I really enjoyed meeting these ‘captive’ cheetahs. I think their life at Mokolodi is pretty sweet.
After my adventure, I went to another co-worker's house briefly (and met his dogs, which was interesting given that I had just petted cheetahs). And then we went to work. Such is the life of a working woman in Botswana.

Language acquisition

After about six weeks in a new place, one might expect to have learned
some of the language, customs and social norms that dictate daily
life. Indeed, I am learning to walk on the left side of the path,
greet people with dumela mma/ raa, and I have even mastered the
customary handshake that involves three distinct hand grasps. One of my
colleagues has taken me under her wing and is teaching me phrases in Setswana;
but I have all but given up on really learning to communicate
effectively in the language.

I am, however, learning a completely different language.. the language
of Botswana-Harvard Partnership's (BHP) Standard Operating Procedures
(SOP's) and Standard Forms (SF's). I have spent the past few weeks
working on the SOP's for research participant clinic visits. Every
research study has a code (ours is BHP041). Because the research we
are doing is on such a large scale, everything has to be standardized
so that data keyers can easily enter information from the standardized
forms into computer databases. A few weeks ago, when I started this
process, I was confused by all of the codes. What does it mean that we
need to complete an HR210, HR201, HR 101 and HR401 during the
post-survey follow-up visit? Now I know that each of these are the
codes for the forms that go along with the DBS & Rapid HIV, HIV ELISA,
CD4 and VL tests respectively. (DBS = dried blood spot; VL = viral
load). What is CN001 and how is it different from a CN002? These are
different versions the consent form that are filled out during
different stages of participation.

This new language, along with some of the tools we are using to store
and share information have been keys to my success at BHP. One of the
most useful tools has been the wiki. All of the SOP's and SF's are on
BHP's wiki and many of the SOP's and SF's are undergoing revisions. (Making these revisions requires a separate set of computer language skills). As
we update SF's and SOP's it is important to ensure that everyone is
working with the most up-to-date versions. With investigators
collaborating from across thousands of miles, this gets to be
confusing-- but somehow it all seems to work out in the end.

So, while I may not be becoming a fluent Setswana-speaker , I am
learning a new language. In fact, when I was learning Spanish in
junior high and high school, my teacher told me that I would know I
have mastered the language (which I never did) when I started dreaming
in Spanish. Well, I haven't had any dreams in Setswana, but I did wake
up one morning wondering about an ST002-PNL (the partner notification
form that we give to participants to invite their partners to
participate in the study).

Go Siame (goodbye).

Botswana Power Company

Oh BPC, my BPC
Botswana Power Company

You’re there for me in so many ways
You make life better most all the days

You keep my computer humming along
You power the radio that sings me a song

You help keep me warm when nights are cold
You power the air con when you’re told

We pay our bill and you light up our house
You don’t complain, you’re quite as a mouse

I know I often take you for granted
And when you’ve failed I’ve raved and ranted

I know the rolling blackouts are needed,
But I’d like to know my plea was heeded.

So, BPC, my BPC
Botswana Power Company:

I wish I may I wish I might,
Have power when it gets dark tonight

But just in case, I've bought a lamp
And I'll pretend I'm at summer camp

And when the power IS on for me
I'll consider it a delicacy

Cause after all, there is more to life
than creature comforts and an easy ride.

2001 to 2010

As I was going to sleep last night, I reflected on the contrasts
between my experiences in South Africa in 2001 and my current
experiences in Botswana in 2010-- specifically related to HIV/ AIDS. During my
time in South Africa in 2001, I worked at an orphanage for children
who had HIV/ AIDS. The children had all presumably contracted HIV in
utero or early in infancy through mother to child transmission. None of the
children in the orphanage were expected to live past the age of 7-- at that
time, kids with HIV progressed to AIDS and died very young. The
primary 'care' we provided to the children was good hygiene, nutrition and
a lot of love (the idea being to shine as much love into their short
lives as possible). I distinctly remember getting news that a set of
twins, whose mother was HIV positive (and the babies were presumed to
be HIV positive) were scheduled to arrive at the orphanage. We
anxiously awaited their HIV test results. When we learned that they
were HIV negative, we were surprised but overjoyed and the twins ended up being
placed in alternative care-- as the orphanage was specifically for
children with HIV/ AIDS.

Fast forward to 2010

This year I am slightly more removed from the physical labor of caring
for people with HIV/ AIDS, and my work focuses on scientific research to
prevent the spread of HIV. I recently had the privilege of visiting
the Baylor Pediatric HIV/ AIDS clinic adjacent to where I work in
Gaborone. Like the children at the orphanage in South Africa, most of the patients at the clinic contracted HIV from their mothers early in life. However, the care available at the clinic offers an inspiring contrast
to the situation I was confronted with in South Africa nine years ago.
The staff at the clinic showed me a graph displaying the average age
of the patients-- which is now extending to 20 years and beyond
(presenting new challenges of transitioning patients to adult-focused
care). Where the bell curve used to be heavily skewed toward high
numbers of infants and young children, those kids are now growing older
which is really changing the make-up of the clinic's patient population.
The prevention of mother to child transmission (PMTCT) through the use of
anti-retroviral therapies has been so successful that, with
appropriate peri-natal care it can be nearly eliminated. I am
astounded by the progress that has been made in nine short years- from
providing nutrition, hygiene and love to support children through
their short lives and early deaths, to nearly eliminating mother to child transmission and having the anti-retroviral drugs available to help children, and all who are infected with HIV/ AIDS live longer, more productive lives.

Human Resources

This week we have been busy reviewing applications and conducting interviews for several key positions within the Mochudi Prevention Project: home-based HIV counselors, a driver and an administrative assistant. I understand that the unemployment situation in Botswana is rather bleak and this was confirmed by the humongous pile of applications we received.

I was very impressed with the professionalism of the BHP human resources department and the precision with which they executed posting of the positions, collection/ review of applications and interviews. The Ministry of Labor must have some pretty tight regulations because they took great care in documenting each applicants' performance within the interview.

My role during the interview process was to run each interviewee through an exercise to demonstrate his/ her competency with technology. This was a very eye-opening experience for me. We had a brief (or so I thought) exercise that involved typing and data entry in a word processing program and a simple spreadsheet computation. I cannot express how fortunate I feel for the fact that I am a digital native and have been around computers (and Nintendo) since I was in Kindergarten. Thank you Granddaddy for those early Apple computers where I made digital doodles and played Webster's Revenge.

The picture above is a typical example of the PILES of paper that surround me each day. The piles are, surprisingly, very dynamic- data-entry specialists and clinicians are continually going through them and shuffling them from place to place. I have been stationed in the Data Management Center (DMC) for most of my time here-- I actually don't have a specific space to sit, but this is where I usually find a seat when I am at BHP Gaborone.

Oh, and I have been getting informal Setswana lessons. Here are a few of my phrases:

Dumela Mma: Hello to a woman
Dumela Rra: Hello to a man

Go siame: goodbye

Umbrellas

This is my limerick about umbrellas- many people carry umbrellas to protect them from the sun.

What can one do with an old umbrella
in the sunny country where they greet you 'dumela'?
Carry it with you when it's hot
and you'll always have a shady spot
It will make you a cool and smart fella