Botswana's HIV Research Articles

Quantitative outcomes of a type 2 single arm hybrid effectiveness implementation pilot study for hypertension-HIV integration in Botswana

BackgroundSuccessful HIV treatment programs have turned HIV into a chronic condition, but noncommunicable diseases such as hypertension jeopardize this progress. Hypertension control rates among people with HIV (PWH) are low owing to gaps in patient awareness, diagnosis, effective treatment, and management of both conditions at separate clinic visits. Integrated management, such as in our study, InterCARE, can enhance HIV-hypertension integration and blood pressure (BP) control.MethodsOur pilot study was conducted in two Botswana HIV clinics between October 2021 and November 2022. Based on our formative work, we adopted three main strategies; Health worker training on HTN/cardiovascular disease (CVD) management, adaptation of HIV Electronic Health Record (EHR) for HTN/CVD care, and use of treatment partners to support PWH with hypertension for implementation. We employed the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework to assess implementation effectiveness and outcomes for BP control at baseline, 6 and 12 months. HIV viral load (VL) suppression was also measured to assess impact of integration on HIV care.ResultsWe enrolled 290 participants; 35 (12.1%) were lost to follow-up, leaving 255 (87.9%) at 12-months. Median age was 54 years (IQR 46–62), and 77.2% were females. Our interventions significantly improved BP control to < 140/90 mmHg (or < 130/80 mmHg if diagnosis of diabetes or chronic kidney disease), from 137/290 participants, 47.2% at baseline to 206/290 participants, 71.0%, at 12 months (p < 0.001). Among targeted providers, 94.7% received training, with an associated significant increase in counseling on exercise, diet, and medication (all p < 0.001) but EHR use for BP medication prescribing and cardiovascular risk factor evaluation showed no adoption. In the intention-to-treat analysis, HIV VL suppression at 12 months decreased (85.5% vs 93.8%, p = 0.002) due to loss to follow-up but the per protocol analysis showed no difference in VL suppression between baseline and 12 months (97.3% vs 93.3%, p = 0.060).ConclusionThe InterCARE pilot study demonstrated that low-cost practical support measures involving the integration of HIV and hypertension/CVD management could lead to improvements in BP control. These results support the need for a large implementation and effectiveness trial.Trial registrationClinicalTrials.gov NCT05414526. Registered 18th May 2022.

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

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.

Drug resistance after cessation of efavirenz-based antiretroviral treatment started in pregnancy.

BackgroundTo reduce risk of antiretroviral resistance when stopping efavirenz (EFV)-based antiretroviral treatment (ART), staggered discontinuation of antiretrovirals (an NRTI tail) is recommended. However, no data directly support this recommendation.ObjectivesWe evaluated the prevalence of HIV drug resistance mutations in pregnant women living with HIV who stopped efavirenz (EFV)/emtricitabine (FTC)/tenofovir disoproxil fumarate (TDF) postpartum.MethodIn accordance with the prevailing Botswana HIV guidelines at the time, women with pre-treatment CD4 > 350 cells/mm3, initiated EFV/FTC/TDF in pregnancy and stopped ART at 6 weeks postpartum if formula feeding, or 6 weeks after weaning. A 7-day tail of FTC/TDF was recommended per Botswana guidelines. HIV-1 RNA and genotypic resistance testing (bulk sequencing) were performed on samples obtained 4–6 weeks after stopping EFV. Stanford HIV Drug Resistance Database was used to identify major mutations.ResultsFrom April 2014 to May 2015, 74 women who had stopped EFV/FTC/TDF enrolled, with median nadir CD4 of 571 cells/mm3. The median time from cessation of EFV to sample draw for genotyping was 5 weeks (range: 3–13 weeks). Thirty-two (43%) women received a 1-week tail of FTC/TDF after stopping EFV. HIV-1 RNA was available from delivery in 70 (95%) women, 58 (83%) of whom had undetectable delivery HIV-1 RNA (< 40 copies/mL). HIV-1 RNA was available for 71 women at the time of genotyping, 45 (63%) of whom had HIV-1 RNA < 40 copies/mL. Thirty-five (47%) of 74 samples yielded a genotype result, and four (11%) had a major drug resistance mutation: two with K103N and two with V106M. All four resistance mutations occurred among women who did not receive an FTC/TDF tail (4/42, 10%), whereas no mutations occurred among 18 genotyped women who had received a 1-week FTC/TDF tail (p = 0.053).ConclusionsViral rebound was slow following cessation of EFV/FTC/TDF in the postpartum period. Use of an FTC/TDF tail after stopping EFV was associated with the lower prevalence of subsequent NNRTI drug resistance mutation.

Modelling the impact of migrants on the success of the HIV care and treatment program in Botswana.

Botswana offers publicly financed HIV treatment to citizens, but not migrants, who comprised about 7% of the population in 2016. However, HIV incidence is not declining in proportion to Botswana's HIV response. In 2018, Botswana had 86% of citizens living with HIV diagnosed, 95% of people diagnosed on treatment, and 95% viral suppression among those on treatment. We hypothesised that continued exclusion of migrants is hampering reduction of HIV incidence in Botswana. Hence, we modelled the impact of including migrants in Botswana's HIV response on achieving 90-90-90 and 95-95-95 Fast-Track targets by 2020 and 2030, respectively. The Optima HIV model, with demographic, epidemiological, and behavioural inputs, was applied to citizens of and migrants to Botswana. Projections of new HIV infections and HIV-related deaths were compared for three scenarios to the end of 2030: (1) continued status quo for HIV testing and treatment coverage, and maintenance of levels of linkage to care, loss to follow-up, and viral suppression among citizens and migrants (baseline); (2) with scaled-up budget, optimised to achieve 90-90-90 and 95-95-95 Fast-Track targets by 2020 and 2030, respectively, for citizens only; and (3) scaled-up optimised budget to achieve these targets for both citizens and migrants. A baseline of 172,000 new HIV infections and 8,400 HIV-related deaths was projected over 2020-2030. Scaling up to achieve targets among citizens only averted an estimated 48,000 infections and 1,700 deaths. Achieving targets for both citizens and migrants averted 16,000 (34%) more infections and 442 (26%) more deaths. Scaling up for both populations reduced numbers of new HIV infections and deaths by 44% and 39% respectively compared with 2010 levels. Treating migrants when scaling up in both populations was estimated to cost USD 74 million over 2020-2030. Providing HIV services to migrants in Botswana could lead to further reductions in HIV incidence and deaths. However, even with an increased, optimised budget that achieves 95-95-95 targets for both citizens and migrants by 2030, the 90% incidence reduction target for 2020 will be missed. Further efficiencies and innovations will be needed to meet HIV targets in Botswana.

A Comparison of Haematological Parameters in a Botswana HIV Cohort in which Cardiovascular Events were Common.

A Comparison of Haematological Parameters in a Botswana HIV Cohort in which Cardiovascular Events were Common.

PARTNERS IN CRIME: PENTECOSTALISM AND BOTSWANA HIV/AIDS POLICY ON CROSS-BORDER MIGRANTS

In this paper I seek to interrogate how the theology of some Pentecostal churches, especially the theology that God heals HIV and AIDS, interacts with the situation of cross-border migrants in Botswana. I also seek to discuss the Botswana HIV policy which denies HIV-positive cross-border migrants access to Anti-Retroviral treatment (henceforth ARVs) which has proven to prolong and improve the quality of life of people living with HIV. Conflict exists between Botswana HIV policy on strict adherence to ARVs and some Pentecostal churches’ insistence that members of their churches living with HIV are healed by God, and therefore they should not take ARVs. While the Pentecostal Church is a ‘home away from home’ for migrants, their theology is in constant conflict and clashes with Botswana HIV health policy, even if the reality is that the same policy denies migrants access to HIV services. It is ironic that both the HIV policy and the Pentecostal theology are in pursuit of preserving life; yet, they both deny cross-border migrants that very life.

Organizational Networks, Divided Policy Authority, and the Effects on Botswana's HIV Response Regime

The UNAIDS framework for HIV response called for 3 "Ones": one strategy, one coordinating authority, and one monitoring framework. Under the direction of President Festus Mogae, Botswana established the National AIDS Coordinating Agency (NACA) to bring together and direct the various government efforts against the epidemic. The African Comprehensive HIV/AIDS Partnership — a PPP bringing together the Botswanan government, Merck Pharmaceuticals, and the Gates Foundation — brought relatively large financial resources to Botswana and became an alternative source of gravity in the Botswanan response. This paper examines how a PPP intended to assist in a national HIV program became a problem: with the advent of ACHAP, practical responsibility for the shape and direction of the national program seemed to have two loci of power. For those trying to help implement Botswana HIV policy, there appeared a division in the locus of power: NACA had the final authority, while ACHAP had the superior resources. I examine the network structure of government and PPP actors, and I analyze how the unintentional division brought about by establishing a PPP lessened anti-HIV action at a critical period in the nation’s response to the disease.

Partners in crime: Pentecostalism and Botswana HIV/AIDS policy on cross-border migrants

In this paper I seek to interrogate how the theology of some Pentecostal churches, especially the theology that God heals HIV and AIDS, interacts with the situation of cross-border migrants in Botswana . I also seek to discuss the Botswana HIV policy which denies HIV-positive cross-border migrants access to Anti-Retroviral treatment (henceforth ARVs) which has proven to prolong and improve the quality of life of people living with HIV. Conflict exists between Botswana HIV policy on strict adherence to ARVs and some Pentecostal churches’ insistence that members of their churches living with HIV are healed by God, and therefore they should not take ARVs. While the Pentecostal Church is a ‘home away from home’ for migrants, their theology is in constant conflict and clashes with Botswana HIV health policy, even if the reality is that the same policy denies migrants access to HIV services. It is ironic that both the HIV policy and the Pentecostal theology are in pursuit of preserving life; yet, they both deny cross-border migrants that very life.

Addressing Ethical Non-Sequiturs in Botswana's HIV and AIDS Policies: Harmonising the Halo Effect

Like many African countries, Botswana is adversely affected by HIV and AIDS. However, from the onset of the epidemic there was an inimical expectation, both internally and externally, that the country would effectively address the problem. The paper posits that this expectation was a partial result of the halo effect emanating from Botswana's successful history on many social, economic, and political fronts. However, whilst the country's HIV and AIDS strategy is one of the success stories of the African continent insofar as the state's commitment is concerned, it is afflicted by ethical impediments that continue to negatively impact the effectiveness of related policies and programmes. The paper examines the loopholes in the Botswana Government's HIV and AIDS response from the perspective of missed opportunities for addressing relevant ethical issues. These include anomalies regarding the lack of targeted sexual health and wellness programmes for prison inmates, sex workers, and sexual minorities. Strategies requiring urgent attention are concerned with provision of HIV prevention, treatment, and care for these populations. The authors contend that inclusive policies, legislation, and programmes to achieve a holistic and ethical response to the epidemic are urgently needed to harmonise the halo effect of Botswana's otherwise positive stance in relation to HIV and AIDS in Africa.

Sexual and reproductive health needs of HIV-positive women in Botswana – a study of health care worker's views

Botswana's HIV prevalence is one of the highest in the world at 31.8% in the 15–49 years antenatal population. Being HIV-positive for a woman presents unique challenges with regard to sexuality, child bearing, and partner relations. To ensure optimal sexual and reproductive health (SRH) of HIV-positive women, it is important to understand how health care workers (HCWs) are prepared to address SRH issues such as contraception, fertility desires, and partner violence. This study reports on a knowledge, attitudes, and practices (KAP) questionnaire completed by 98 HCWs from clinics located in and nearby Gaborone and analyzed using descriptive and nonparametric statistics. The majority of participants were nurses (43%), health educators (27%), and lay counselors (19%), 82% female, median age of 35 (Interquartile Range (IQR): 29.25–43.75). General HIV/AIDS knowledge was high with a median score of 8.0/9 (89%) (IQR: 8–9). However, the median SRH knowledge score was much lower at 6.0/10 (60%) (IQR: 4–7). Of the three groups, the SRH knowledge scores of lay counselors were significantly lower than nurses (p=0.024). The attitude scores pertaining to issues such as family planning, sexual violence, the health system's ability to offer SRH services, and personal ability to offer SRH services were moderately positive with a median score of 75% (IQR: 69–81%); although nearly 25% of respondents felt that it is irresponsible for an HIV-positive woman to want to have a child. When presented with a case study of an abused, HIV-positive pregnant woman, most respondents indicated they would offer supportive care without judgment; however 28% of respondents indicated they would express disapproval or disappointment for becoming pregnant when she knows she is HIV-positive. The low SRH knowledge scores together with discriminatory attitudes and practices emphasize the need for increased and ongoing training in SRH issues for all HCWs who provide care for HIV-positive women.

The Madikwe Forum: a comprehensive partnership for supporting governance of Botswana's HIV and AIDS response

There is a need for actors within the philanthropic sector to pursue collaborative partnerships with developing nations which could result in sustainable country-led responses to HIV and AIDS. There is also a need to evaluate the structures governing these partnerships in order to determine their effectiveness in strengthening national responses to HIV and AIDS. This article presents findings from a qualitative study of a governance structure of the African Comprehensive HIV/AIDS Partnerships (ACHAP), namely the Madikwe Forum. The investigation sought to critically reflect on the role and effectiveness of the Madikwe Forum in Botswana's response to HIV and AIDS and to consider the value of such a forum for other developing nations and partnership arrangements. The findings indicate that the Madikwe Forum has enabled considerable progress in the implementation of ACHAP-supported initiatives in Botswana. The constructive working relationship and close alignment between ACHAP and the Botswana government's objectives and priority areas were viewed as critical to this success. However, problems exist regarding the operation of the forum as well as a lack of focus on monitoring and evaluation, which requires the forum's urgent attention.