Botswana is a landlocked country in southern Africa, to the north of South Africa. Its population is mainly concentrated in the eastern part of the country and it has borders with Namibia, South Africa and Zimbabwe. The country is divided into nine districts and five town councils*: Central, Francistown*, Gaborone*, Ghanzi, Jwaneng*, Kgalagadi, Kgatleng, Kweneng, Lobatse*, North West, North East, Selebi-Pikwe*, South East and Southern. The study sites were located in North West (Maun), Central (Serowe and Mahalapye) and Kweneng (Molepolole) districts. Serowe and Maun were among the pilot sites and Mahalapye and Molepolole were the second generation facilities (Figure 3.1).

Figure 3.1: Map of Botswana showing the study sites

3.4.1 Maun

Maun is located in the north of Botswana and is a peri-urban tourist village with a population of over 124 000 (Ngami and Okavango) (Central Statistics Office (CSO), 2001). The village is home to a wide range of people of different backgrounds and a number of tourist companies are based there. It is the capital village of the North West district and most of the major council offices are located there. The Government hospital is situated in the central part of the village. At the time of the report, the hospital had 2690 registered patients, of whom most (2492) were on ART. There are three primary hospitals within 300 kilometres which also offer ARVs (Ghanzi to the south-west, Gumare to the north and Gweta to the south-east of Maun).

The ART patients are seen at the Infectious Disease Control Centre (IDCC) clinic which is located in a Portakabin close to the hospital entrance gate. The clinic is open Monday to Friday from 0730 hours. All the different units required to serve the patients are enclosed to form a quadrangle. The building is spacious and clean and has a waiting area that is large enough to accommodate patients. The entrance opens onto the reception area, where patients are registered for the day and given appointment numbers, and patient files are prepared and taken to the relevant officer. The clinic starts with a morning prayer and health talk organized by the staff for all patients in the clinic. The patients then disperse, moving on to the appropriate unit for their appointments.

3.4.2 Serowe

Serowe is a peri-urban village situated in the central part of the country. It is the capital of the Central District Council and many Government offices and other departments are located there. It is home to the Bangwato tribe. There are two tertiary institutions: Serowe College of Education and the Institute of Health Sciences. The Botswana Defence Force training camp is located about 40 kilometres from the hospital.

Sekgoma Memorial Hospital, a district hospital, was built over 75 years ago. However, regular maintenance has ensured that the buildings and surroundings are clean. The hospital serves the over 42 000 residents of Serowe (CSO, 2001), as well as patients from its catchment area which has a population of over 153 000. At the time of the study, the hospital had 3403 patients - all of them on ART. The ART programme was started in the hospital in May 2002. At that time, the treatment centre consisted of a resource centre and a prefabricated unit with a conference room and two consulting rooms with a very small reception area. This unit and what would later be the definitive IDCC building were built through funding from ACHAP. The IDCC is now a very large pre-fabricated structure located by the hospital entrance gate. It has two major entrances, one leading to the reception for consultations and counselling and another leading to the ARV dispensary. The unit provides adequate space for patients and health care workers. The clinic is open Monday to Friday from 0730 hours. It also opens occasionally on public holidays to cater for patients who may have run out of pills. Patients are received within the reception area and issued with numbers on a first-come-first-served basis, although priority is given to very sick patients and emergencies. A member of the health team, invited priests and others lead the patients in morning prayers and devotion. This is followed by a health talk about HIV, AIDS and ARVs which is given by a nurse or lay counsellor (usually a person living with HIV (PLWHIV)). This talk includes the use of audiovisual aids and covers HIV infection, prevention, disease progression, treatment with ARVs and monitoring, side-effects, nutrition and adherence issues. Patients are registered by data clerks, and nurses check their vital signs before directing them to the appropriate room for consultation or counselling. The hospital now has capacity for CD4 testing, but this was not available at the time of the study.

3.4.3 Mahalapye

Mahalapye is a peri-urban village located in the central part of the country. It is the capital of the Mahalapye central sub-district and most of the council's major offices are located here. Mahalapye Government Hospital is in the central part of the village. It is a 95-bed hospital which offers outpatient services, maternity services and general inpatient care. It serves as a referral facility for 44 health facilities in the sub-district, comprising one primary hospital, 15 clinics, 28 health posts and mobile clinics. Mahalapye sub-district has a total population of almost 110 000 people (Mahalapye District Health Team, 2005). It has four satellite clinics which refer patients to the IDCC when treatment is initiated. The hospital is located 200 kilometres to the north of Gaborone, along the main trunk road that runs across the country from the south to the north. There is one primary hospital within 100 kilometres of this village which also provides ART.

At the time of the report, the hospital had 1960 registered patients of whom 1836 were on ART. Patients are seen at the IDCC clinic which is in a separate block of buildings located behind the main hospital. It is open on weekdays, with the exception of public holidays. All the different units required to serve the patients are grouped together, with the exception of the laboratory which is in the main hospital complex. The clinic is spacious and clean, but has only a small waiting area for patients. Patients meet the nurse on duty and their files are processed from the booking register, according to the order in which they arrived. They then queue to see the medical officer before going to the pharmacy to collect their medications.

3.4.4 Molepolole

Molepolole is a peri-urban village 50 kilometres to the west of Gaborone. It is the capital village for Kweneng district, which has a population of over 230 000 (CSO, 2001). The Scottish Livingstone Hospital is one of the second generation hospitals to offer ART. At the time of this report, the hospital had 2284 patients enrolled, of whom 1879 were on treatment. Although there is a primary hospital 40 kilometres south of Molepolole which also offers ART, there are no hospitals to the north and west which provide treatment services. As a result, some patients travel up to 200 km to access treatment at the Scottish Livingstone Hospital. The hospital consists of old buildings but a new ultra-modern hospital is currently under construction on an adjacent site. The existing hospital does not have a separate building for ART patients. All outpatients are attended to in the hospital outpatients unit, which has two separate consulting rooms for patients who come for AIDS management.

The ARV clinic operates four days a week from Monday to Thursday. All outpatients have their vital signs checked at the same reception area. Then patients who have come for AIDS management are given a number in a patient card - which is a different colour from the cards given to other outpatients - and join the queue for one of the two consulting rooms reserved for them. After the consultation, the ART patients go to collect their medication from the pharmacy which is housed within the outpatients department, while the other patients go to a different building to collect their medications. Adherence counselling and HIV-related specimen collection are provided at the resource centre, a Portakabin situated very close to the outpatients department. There is a television in the reception area/waiting room, and a conference room where patient education and counselling is done. Some reference books and videos are also available for patients' use. The Portakabin is often packed to capacity and some patients wait outside on the stone-paved area. Ambulances from different health posts and clinics are parked within the hospital. Ambulance transport is provided free of charge for ART patients who are very sick. Other ART patients can sometimes avail themselves of this transport if there is available space or if there is no public transport available to take them to the treatment centre.