Five years after Treat All implementation: Botswana's HIV response and future directions in the era of COVID-19.

Keith Jefferis,Dinah Ramaabya,Joseph N Jarvis,Siphiwe Ratladi,John Stover,Bornapate Nkomo,Ava Avalos,Heston Phillips,Charles Muthoga,Mpho Mmelesi,Robert Selato

doi:10.4102/sajhivmed.v22i1.1275

Abstract

BackgroundAs the relentless coronavirus disease-2019 (COVID-19) pandemic continues to spread across Africa, Botswana could face challenges maintaining the pathway towards control of its HIV epidemic.ObjectiveUtilising the Spectrum GOALS module (GOALS-2021), the 5-year outcomes from the implementation of the Treat All strategy were analysed and compared with the original 2016 Investment Case (2016-IC) projections. Future impact of adopting the new Joint United Nations Programme on HIV/AIDS (UNAIDS) Global AIDS Strategy (2021–2026) targets and macroeconomic analysis estimating how the financial constraints from the COVID-19 pandemic could impact the available resources for Botswana’s National HIV Response through 2030 were also considered.MethodProgrammatic costs, population demographics, prevention and treatment outputs were determined. Previous 2016-IC data were uploaded for comparison, and inputs for the GOALS, AIM, DemProj, Resource Needs and Family Planning modules were derived from published reports, strategic plans, programmatic data and expert opinion. The economic projections were recalibrated with consideration of the impact of the COVID-19 pandemic.ResultsDecreases in HIV infections, incidence and mortality rates were achieved. Increases in laboratory costs were offset by estimated decreases in the population of people living with HIV (PLWH). Moving forward, young women and others at high risk must be targeted in HIV prevention efforts, as Botswana transitions from a generalised to a more concentrated epidemic.ConclusionThe Treat All strategy contributed positively to decreases in new HIV infections, mortality and costs. If significant improvements in differentiated service delivery, increases in human resources and HIV prevention can be realised, Botswana could become one of the first countries with a previously high-burdened generalised HIV epidemic to gain epidemic control, despite the demands of the COVID-19 pandemic.

Highlights

Botswana has made substantial gains against the HIV epidemic and is one of the few countries in Africa to have reached the Joint United Nations Programme on HIV/AIDS (UNAIDS) 90-90-90 targets.[1]. It was one of the first African countries to successfully implement a Treat All strategy, which included antiretroviral (ART) treatment optimisation using the integrase inhibitor dolutegravir, following extensive programmatic and economic modelling contained within the 2016 Investment Case (2016-IC).[2]
Inputs for the Resource Needs and Family Planning modules of Spectrum were derived from published reports, strategic plans, programmatic data and expert opinion (See Appendix 1: Inputs and targets by 2030 for the 2016-IC, AIM-2020, GOALS-2021 and the UNAIDS Global AIDS Strategy and Appendix 3: Data sources for Spectrum)
Additional Spectrum modules used for this analysis included DEMPROJ for demographic characteristics of the population by age and sex, including assumptions on fertility, mortality and migration; AIM to estimate the consequences of the HIV epidemic, such as the number of people living with HIV (PLWH), new HIV infections, and AIDS deaths; FAMPLAN to determine the family planning requirements to reach national goals; GOALS to estimate the costs and impact of the http://www.sajhivmed.org.za

Summary

Introduction

Botswana has made substantial gains against the HIV epidemic and is one of the few countries in Africa to have reached the Joint United Nations Programme on HIV/AIDS (UNAIDS) 90-90-90 targets.[1]. Remains critical to clearly delineate and prioritise the areas of HIV prevention, treatment and care that will have the greatest impact to ensure economic and programmatic sustainability over the decade. To this end, in cooperation with the Ministry of Health and Wellness and National AIDS and Health Promotion Agency, a technical working group composed of programmatic, economic, clinical and modelling experts used the GOALS module of Spectrum (GOALS-2021) to analyse the 5-year outcomes since the implementation of the Treat All strategy in 2016. As the relentless coronavirus disease-2019 (COVID-19) pandemic continues to spread across Africa, Botswana could face challenges maintaining the pathway towards control of its HIV epidemic

Methods

Discussion

Conclusion