Tourists who visit Botswana’s scenic Okavango Delta rarely visit Shakawe, the most remote village participating in the Botswana Combination Prevention Project (BCPP), a large HIV-prevention trial of over 100,000 people. The results of the trial will likely end up as an orderly table published in a prestigious medical journal. Though the numbers in that table may provide much-needed evidence on how best to operate HIV/AIDS programs across the globe, they won’t show the hard work, mistakes, corrections, and triumphs of the field team. The data won’t reveal the thousands of daily interactions between the Research Assistants (RAs) and the villagers—the stories condensed into each data point.
In September 2015, the field team was finishing up the Baseline Household Survey in Shakawe. They had been in the village for a month. Keotshepile Molokwane, a 27-year-old RA who everyone calls Keo, had one last visit to complete.
The BCPP driver maneuvered the SUV through the sand. When the road ended, he helped Keo get his gear from the back of the vehicle. By the time he was loaded up, Keo was carrying a MacBook Air, a phone, a GPS, a bag of phlebotomy supplies and HIV tests, a cooler bag with an ice pack, a CD4 test kit the size and weight of a six-pack, and a small folding table.
“We are trying to make testing to be easy, to be more friendly, more accepted,” said Keo, who wore a white coat over his polo shirt. “We’re bringing the clinic to them.”
Laden with equipment, he trudged through the hot sand, passing several rondavels—round earthen houses with thatched roofs. GPS in hand, he located the right one in a compound that contained several houses, a faucet in the yard, and an outhouse, all bordered by a chicken-wire fence.
The woman he was looking for was at home. She wore a print blouse, black skirt, and black canvas shoes. She was maybe a little older than Keo and had a warm smile. To ensure privacy, RAs arrange for discussions and testing to take place out of earshot of other family members, unless a participant wants them to be there. The woman said she’d prefer to talk outside, so Keo unfolded his table and set up his makeshift office in the sand. The woman brought out two chairs—a plastic chair and a metal chair missing its seat. The RAs had been instructed to always take the least comfortable chair, so Keo took the seatless chair and sat forward on the edge.
He spoke to the woman in Setswana. The team had anticipated a language problem in Shakawe where a large number of people are ethnic Bambukushu, but almost everyone, it turned out, spoke Setswana. Keo had been to the household several times before to enroll other family members.
Without rushing, he went through the consent form that the woman had to sign to participate in the trial. He explained what the trial was about, what participating involved, and how, if she did agree to enroll, she could withdraw at any time. The woman asked a few questions. After Keo answered, she signed the form. A skinny chicken wandered around the yard. Two young boys ate fruit and ran around in circles.
With the consent form signed, Keo proceeded with the detailed questionnaire that’s part of the Baseline Household Survey. The questions cover socio‐economic information, residency status, and sexual activity. He went through the questions unhurriedly, listening closely when the woman spoke and recording her answers on his MacBook Air. There was a nice rapport between them.
When the questionnaire was complete, Keo moved his laptop to the side, opened a bag, and took out supplies for the HIV test. He pulled on latex gloves. The woman giggled nervously when she gave him her hand to draw blood. He pricked her finger, collected the samples, then labeled each tube with a black marker. By now the table was crowded with alcohol wipes, a yellow cup for sharps, and a red biohazard bag. Keo prepared the HIV test and set a timer for 20 minutes. If the result was positive, he would do a CD4 test immediately after to measure the health of the woman’s immune system.
They talked as they waited. Keo used the time to answer additional questions. Afternoon clouds rolled across the sky, making the hot day a little bit cooler. The woman kicked off her shoes. When her cell phone rang, she took the call at the table. On the other side of the chicken-wire fence, children dressed in white shirts and gray pants or skirts walked home from school.
Minutes later the timer went beep-beep-beep. Keo pushed the button to quiet it. He checked the HIV test results. He and the woman spoke calmly for a few more minutes, then the interview ended. Keo packed his equipment, folding up the small table last. He and the woman shook hands. Then, giggling, the young boys who’d been playing in the yard ran up to Keo and he shook their hands as well.
Back to Base
Two trailers parked outside the Shakawe clinic served as the field team’s base of operations in the village. One trailer houses a mobile laboratory with storage space for the RAs’ equipment. The other serves as working space for the IT team and a charging station for laptops.
When Keo neared the IT trailer, his laptop automatically connected to the secure Wi-Fi network created for the team. Without his having to do anything, the encrypted information on his MacBook Air synchronized onto the central server.
After returning his laptop to the charging station, Keo handed his blood samples to the technician in the mobile lab. The samples are temperature sensitive and must be quickly processed. Once processed, they’re packed in dry ice and kept at an ultra low temperature. The next day, a courier would pick up samples and drive them 700 miles to the Botswana Harvard Partnership Lab in Gaborone.
With his work done for the day, Keo joined the other RAs sitting in plastic chairs outside the trailers—their equivalent of an employee lounge. The temperature was still in the 90s, with little shade. The team was in good spirits after their month in Shakawe. In a few days, they would have to move to a village hundreds of miles away, find new places to live, and begin knocking on doors again.
But for now the team was enjoying their accomplishments in Shakawe. When planning the study, Shakawe and Gumare, its paired village 80 miles away, were expected to be the most challenging because of their remoteness and ethnic diversity. Counter to expectations, the team had done well here, finishing early and over quota. They had now completed 13 of the 15 pairs of villages in the Baseline Household Survey.
Though work at the start of the study had been harder than anticipated as procedures were being worked out and systems refined, operations were now running smoothly. The team could appreciate how much they had adapted and how well they worked together. That evening, Keo and the Shakawe team would join their Gumare colleagues for a goat roast to celebrate just how far they had come.
Title Photo: Keotshepile Molokwane (right) interviews a woman in her yard in Shakawe. Photos by Dominic Chavez
Martha Henry is the Director of Communications for the Harvard T.H. Chan School of Public Health AIDS Initiative.