Botswana the first country in the region to provide universal free antiretroviral treatment to people living with HIV.
Botswana has demonstrated a strong national commitment in responding to its HIV and AIDS epidemic and has become an exemplar for many in sub-Saharan Africa. It was the first country in the region to provide universal free antiretroviral treatment to people living with HIV, paving a path for many other countries in the region to follow. The impact of its treatment programme has been widespread. New infections have decreased significantly, from 15,000 in 2005 to 9,100 in 2013, although in recent years they have begun to rise again, with 9,700 reported in 2015. AIDS-related deaths have dramatically decreased from the 14,000 recorded in 2005. They fell to 3,200 in 2015.3
Botswana is a middle-income country4 which faces a huge challenge in sustaining its impressive HIV response as donors increasingly focus on low income countries. Many donors have reduced or withdrawn their funding in recent years. PEPFAR alone has more than halved its funding, from $84 million in 2011 to $39 million in 2015.5
Key affected populations and HIV in Botswana
The HIV epidemic in Botswana is widespread although several key populations are hit hardest by HIV. There is an increasing effort at a national level to support these key affected populations, but legal and punitive barriers prevail, making HIV prevention and support efforts challenging.
In 2012, for the first time, key populations including female sex workers and men who have sex with men were included in HIV epidemic surveys, allowing for a better understanding of HIV among these populations.6
As of 2016, Botswana does not have a specific strategy that addresses the needs of key affected populations, although its current National Strategic Framework (NSF) for HIV and AIDS makes reference to ‘all inclusive programming’.7 Currently, HIV prevention programmes are reaching only 44.9 % of these key affected populations. With more than half not being reached, HIV prevention efforts need to be scaled up to support and incorporate the most vulnerable in Botswana’s HIV epidemic.8
In August 2014, Botswana’s Supreme Court ruled that all HIV positive prisoners, regardless of nationality, must be provided with public access to antiretroviral treatment, indicating that this group may also be disproportionately affected by HIV. Despite this, there is currently little public information about the HIV status of prisoners in Botswana.9
Female sex workers and HIV in Botswana
Botswana’s current data on female sex workers is based on a 2012 study of Francistown, Gaborone and Kasane.10 It found HIV prevalence to be 61.9% among an estimated 4,000 female sex workers in the three districts.11
About half (54.8%) had tested for HIV and 67% reported consistent condom use. Those female sex workers who reported not using condoms indicated that they were paid not to do so, and 18.6% reported they were forced not to use condoms.12 It is therefore critical that HIV prevention efforts focus on the clients of female sex workers as well as the sex workers themselves. There is an increased need to encourage HIV testing among this group, allowing more female sex workers to know their status and seek appropriate treatment if necessary.
Men who have sex with men and HIV in Botswana
Another key affected population in Botswana is men who have sex with men (sometimes referred to as MSM). Homosexuality is illegal in Botswana and, due to this punitive law, providing HIV services for this population is inherently difficult.
As with female sex workers, current data is based on a 2012 study of three districts. This estimates HIV prevalence among men who have sex with men at 13.1%. Around 66% reported consistent condom use during anal sex in the last six months, although 60% were not aware that anal sex is associated with higher risks of HIV acquisition. Less than half (49.4%) reported receiving HIV related information in the past year. Just under half (46.7%) reported having female sexual partners in the past six months.13
Although criminalisation is impeding progress, positive strides are being made at a national level, with members of government openly discussing the importance of working with men who have sex with men as part of Botswana’s HIV response.14
Young people and HIV in Botswana
Considering that in 2000, a 15-year-old had more than a 50% chance of dying from an AIDS-related illness, Botswana has made substantial progress in the fight against HIV and AIDS for young people.15
According to the last population census in 2011, slightly more than a fifth (426,400) of Botswana’s population are aged 15-24 years old. In 2013, HIV prevalence among this age group was 4.74%, compared to 6% in 2005.16
Despite some progress, HIV knowledge among young people remains dangerously low, with less than half (47%) of those between 15 and 24 able to correctly answer basic questions in relation to HIV. There is very little difference in knowledge between young men (47.1%) and young women (47.4%).17
Women and HIV in Botswana
Around 190,000 women were estimated to be living with HIV in 2015, compared to 150,000 in 2005.1920 This means more than half (54%) of those living with HIV are women.21 Gender inequality in Botswana is fuelling the epidemic among females. Factors such as early sexual debut, forced marriage and gender-based violence (GBV) have increased their vulnerability to HIV.
According to a national study into GBV in 2012 - the most recent of its kind - 29% of women in Botswana reported experiencing some form of intimate partner violence during the past 12 months. 62% reported experiencing intimate partner violence in their lifetime.22
Botswana’s national strategic HIV response has aimed to reduce these inequalities, focusing on the provision of psychosocial services for young women, female economic empowerment and greater focus on effective HIV prevention programmes for secondary school girls.23
HIV testing and counselling (HTC) in Botswana
HIV testing remains low across Botswana. It increased slightly from 61.7% in 2008, but remained under 70% in 2012.24 In 2014, 315,185 people aged 15 years and older received HTC and knew their results during the past 12 months, with more women testing than men.25
Botswana provides HTC services through a network of public and private health facilities and sites run by non-governmental organisations. In 2014, 636 public health facilities and 32 civil society facilities were providing HTC. There is no data from the country’s private sector.26
The government and external funders have supported voluntary testing services (VCT) since 2000. The centres provide immediate, confidential VCT services for sexually active people in Botswana aged 18-49.27
In 2013, Botswana took part in a Guinness World records-breaking HIV testing campaign alongside South Africa and Tanzania. The campaign, supported by UNAIDS, aimed to increase HIV testing awareness and importance. Across 20 testing sites in the three countries, 4,367 people were tested over an eight-hour period.28 The country director for UNAIDS in Botswana stated regarding the record breaking campaign:
This campaign addressed one of the major challenges in the national AIDS response. An estimated one of three adults in Botswana have never tested for HIV and do not know their HIV status.29
The impact of this highlights the importance of HIV testing campaigns. Establishing VCT centres is crucial but highlighting the importance of HIV testing in the community and increasing awareness of testing is vital in increasing the numbers of people going for HIV tests.
The government introduced routine HIV testing in 2004, with HIV tests being offered as a routine part of check-ups in public and private clinics in Botswana. The testing is routine, but if people do not want to be tested they can ‘opt out’. Botswana was the first country in Africa to have a national policy of routinely offering an HIV test at clinics.30
In April 2013, mandatory HIV testing became legal in Botswana. This enables directors or authorised personnel to force someone to take an HIV test and disclose their status if requested. This has been contested by many civil society and human rights organisations, arguing that it is a step backwards for Botswana and could contribute towards increased HIV stigma and discrimination within the country.31
Civil society organisations role in HIV testing
Despite a strong national response to HIV, many civil society organisations have played a vital role in providing HIV testing and support services. They have also played a critical role in advocating for improved HIV services, especially for more marginalised populations. Providing a voice to these groups, however, has been difficult, with many of the organisations still heavily reliant on government aid, restricting the role they can take in policy reform.32
HIV prevention in Botswana
While Botswana has shown significant progress in areas concerning HIV treatment and care, specific areas within HIV prevention have not been as effective. The vast majority (85%) of condoms that are available in Botswana are available for free.33. On average, 50 condoms a year are available for every man in Botswana. This exceeds the United Nations Population Fund (UNFPA) regional benchmark of 30 male condoms distributed per man per year (2011–2014).34. Comprehensive HIV knowledge and condom use remains low in Botswana and efforts in this area require attention.
Condom use has decreased over time in Botswana, from 90.2% of people claiming to use condoms during sex, in 2008, to 81.9% in 2012, the most recent data available. Botswana is struggling to challenge the myths and views surrounding HIV prevention and transmission, with cultural beliefs pervasive in many areas of the country.35
The understanding of HIV and AIDS by the community is critical to informing HIV prevention programme implementation. Research has found that in many communities, traditional healers view HIV not as a new disease but as an ‘old’ Tswana disease. It has been argued that this has implications for many of the national HIV prevention programmes which are based around biomedical terms.36
HIV prevention programmes
The first national HIV programme in Botswana was in 1988. Different strategies have evolved since then. One of the most famous and successful programmes is the teacher-capacity building programme which was launched in 2004 by the Ministry of Health and United Nations Development Programme (UNDP). The programme aims to improve teachers’ knowledge to demystify and reduce stigma surrounding HIV and AIDS. As part of the project an interactive AIDS education programme called Talk Back was aired twice a week by Botswana television and shown in schools. Since its inception, Talk Back has reached more than 20,000 teachers and 460,000 students. The teacher-capacity building programme has been one of Botswana’s successful HIV prevention programmes, winning awards for its contribution and services to the HIV response.37
Makgabaneng, a popular, long-running radio serial drama, is another example of the way Botswana has utilised mass media for HIV prevention. The series addresses a range of themes related to HIV within Botswana, such as faithfulness, cultural traditions, treatment and services. Makgabaneng additionally provides HIV services and information at roadshows and health fairs, reaching more than 20,000 people through these programmes in 2013.38
Botswana’s current HIV prevention strategy includes a commitment to invest more in behavioural interventions that increase knowledge about HIV among young people and key populations.39
Prevention of mother-to-child transmission (PMTCT)
Botswana’s prevention of mother-to-child transmission (PMTCT) programme is one of the most successfully implemented HIV programmes within Botswana’s HIV response.
In 2014, the PMTCT programme was available in all 634 health facilities that provide maternal child health services.40
Around 92% of pregnant women living with HIV in Botswana received antiretroviral treatment in 2015. This is a decline in coverage, which stood at 95% in 2013.41 42. This equates to around 11,900 women, around half of whom were already on treatment before their pregnancy.43
The estimated percentage of HIV infections among newborns from HIV-positive women delivering in the past 12 months was 1.8% in 2014, compared to a high of 2.49% in 2013. This equates to fewer than 500 infants.44
Male involvement in PMTCT remains low. It stood at 18% in 2014, although this is a slight increase from the 2011 level of 11%.45
Voluntary medical male circumcision VMMC
Most men who have volunteered for circumcision have been adolescents and young adults. Botswana’s target is for 80% of HIV negative men (aged 0-49 years) to have undergone VMMC by 2016. It is unlikely to meet this, with a major effort underway to increase the demand for VMMC through house-to-house mobilisation and social media.47
Antiretroviral treatment (ART) in Botswana
Botswana's Masa antiretroviral treatment programme launched in 2002. It has become one of the most successful antiretroviral treatment programmes in sub-Saharan Africa.
The key characteristics of Masa are that it is universal and free, making antiretroviral treatment available to all eligible citizens. Botswana was the first African country to establish a national HIV treatment programme and it has developed substantially over the last decade.48
It was estimated that, in 2015, around 264,000 adults living with HIV were receiving antiretroviral treatment – a coverage of 78%, up from 69% in 2013. Coverage among children has also risen to more than 95%.49
In 2016, in line with World Health Organization treatment guidelines, Botswana launched a ‘treat all’ strategy. This aims to start anyone who tests positive for HIV on treatment immediately, regardless of their CD4 count (which indicates the level of the virus in the body).
Although Botswana’s ART programme has done well, concerns exist around the number of adults who test positive but do not continue onto treatment. This is known as the ‘loss to follow-up rate’, which has steadily increased among adults in recent years. An increase in the first line treatment failure rate – the first type of ART someone is given – has also been recorded, from less than 6% in 2012 to over 10% in 2013.50.
ART coverage is also compromised by a low testing rate. Only 63.7% of people aged 15- 49 had an HIV test and were informed of the results in the past 12 months in 2014.51
Barriers to HIV prevention
A strong and committed national response has ensured that many HIV programmes have been effectively implemented. However, like many countries in sub-Saharan Africa, barriers prevail that are impeding progress in the fight against HIV and AIDS.
One of Botswana’s greatest challenges in responding to HIV is funding. The National AIDS Coordinating Agency (NACA) projects that costs for Botswana’s HIV response will rise from $274 million in 2014 to $339 million in 2030.52
Due to Botswana’s upper-middle income country status, many international donors have been withdrawing funding and instead directing their donor support to low-income countries. For example, PEPFAR has more than halved its funding, from US$84 million in 2011 to US$39 million in 2015.53. In 2013, the Gates Foundation withdrew funding all together and the Centre for Disease Control and the African Comprehensive HIV/AIDS Partnership withdrew funding for safe male circumcision.54 This has implications for Botswana’s national prevention and treatment programmes.
Financial security and sustainability is also critical for providing universal access to antiretroviral treatment, allowing Botswana to continue with their highly successful treatment programme. A lack of human resources has also become a major challenge for Botswana. The withdrawal of donor support and funding has brought a cut in donor supported positions.
In order to address this issue, in 2015 Botswana produced a national HIV investment framework that promotes effective, efficient and sustainable investments in their HIV responses by targeting specific locations and populations.55
Gender inequality in Botswana is a major barrier to HIV prevention efforts in the country. Despite new HIV infections declining among women aged between 15 and 49, from 5,900 in 2009 to 4,500 in 2013 , a number of factors remain that increase women’s vulnerability to HIV.56 Early sexual debut, forced marriage and gender-based violence have all been found to increase the risk of HIV transmission.
A number of policies were developed in 2013 that enabled the general population to obtain health care without discrimination. Despite these important steps, as of 2016 no policies have been developed to protect sex workers and men who have sex with men. HIV prevention programmes working with these key affected populations face many barriers that increase stigma and discrimination towards these populations.
The future of HIV and AIDS in Botswana
A strong and committed national HIV response in Botswana has enabled significant progress in tackling the HIV epidemic across the country. Continuing this approach will be critical in the years to come, with the country facing significant financial cuts to their HIV funding and support.
In particular, NACA has identified the following interventions as important for future work: immediate treatment enrolment for people who test positive for HIV (known as ‘test and treat’); the introduction of pre- exposure prophylaxis (when someone who is HIV negative is given ART before potential exposure to HIV in order to prevent transmission) and community HIV testing, including self-testing and new treatment regimens.57
Despite significant progress in HIV treatment coverage for pregnant women and children, increasing the coverage for other members of the population, including key affected populations and young people will also be critical for the future success of Botswana’s HIV response. An increased awareness of the importance of testing will also be key for prevention efforts.
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