Botswana has the third highest HIV prevalence in the world, after Lesotho and Swaziland at 21.9%.1 Prevalence has declined in recent years from 25.4% in 2005 to 21.9% in 2013.1 Botswana has demonstrated a strong national commitment in responding to its HIV and AIDS epidemic.
Leading the way in prevention and treatment programmes, Botswana has become an exemplar country for many other sub-Saharan African countries. Botswana was the first sub-Saharan African country 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 the treatment programme has been widespread. New infections have decreased significantly from 15,000 in 2005 to 9,100 in 20131, and AIDS-related deaths have dramatically reduced from 14,000 in 2005 to 5,800 in 2013.
Botswana, now a middle-income country2, faces its greatest challenge- sustaining their impressive HIV response in the face of decreased funding. Many donors have decreased and withdrawn funding, PEPFAR funding alone decreased by over 30 million US$ between 2009 and 2012.3
Key affected populations and HIV in Botswana
The HIV epidemic in Botswana is widespread however there are several key populations that are hardest hit by HIV. There is 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 (MSM) were included in HIV epidemic surveys, allowing for a better understanding of the HIV epidemic among these populations.3 Currently, HIV prevention programmes are reaching only 44.9% of these key affected populations. With over half not being reached, HIV prevention efforts need to be scaled-up to support and incorporate the most vulnerable in Botswana’s HIV epidemic.
Female sex workers and HIV in Botswana
HIV prevalence among female sex workers (FSW) is high in Botswana at 61.9%, more than three times that of the general HIV prevalence.3 Despite more than 80% of sex workers reporting using condoms, female sex workers are often working in high-risk environments where circumstances can change depending on the client.4 Research in Botswana has found that in many instances sex workers can be paid additionally to not use condoms, or be forced to not use condoms by clients, increasing their vulnerability to HIV infection. It is critical that HIV prevention efforts among these populations need to focus both on FSW and their clients.5
HIV testing remains low among female sex workers, at 54.8%. There is an increased need to encourage HIV testing among these populations, so that more FSW know their status and can seek appropriate treatment if necessary.3
Men who have sex with men and HIV in Botswana
Another key affected population in Botswana is men who have sex with men (MSM). Homosexuality is illegal in Botswana and due to this punitive law, providing HIV services for this population is inherently difficult. HIV prevalence among this population is 13.1%. Estimations state that over 80% of MSM use condoms during sex, however stigma and discrimination towards this group is still highly prevalent, preventing MSM from seeking HIV testing services and support.4
Despite national strategic goals that aim to address these key affected populations within the epidemic, criminalisation is impeding progress. It has been found that positive progress is being made at a national level, with members of government openly discussing the importance of working with MSM in Botswana’s HIV response.6
Young people and HIV in Botswana
HIV prevalence among young people has reduced over the last decade, falling from 6% of 15-24 year old living with HIV to 3.5%.1 Considering that in 2000, a fifteen 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.7
Despite this progress, HIV knowledge among young people remains dangerously low, with fewer than 50% of people aged 15-24 able to correctly answer basic questions in relation to HIV.3 HIV prevention knowledge is particularly low among young males.3 Increased youth-friendly health services and youth involvement in HIV intervention planning will enable more policies and practices that are young people focused, and will enable more widespread comprehensive HIV knowledge.
Women and HIV in Botswana
Women are disproportionately affected by the HIV epidemic in Botswana. Over 50% of the people living with HIV are women, with 180,000 women living with HIV in 2013, which has increased from 150,000 in 2005.1 Gender inequality in Botswana is fuelling the epidemic among females. Factors such as early sexual debut, forced marriage and gender-based violence have increased their vulnerability to HIV.
One survey found that 28.9% of women over the age of 18 had experienced some form sexual based violence in their lifetime.3 Botswana’s national strategic HIV response has aimed to reduce these inequalities, aiming to focus on the provision of psychosocial services for young women, female economic empowerment and greater focus on effective HIV prevention programmes for secondary school girls.3
HIV testing and counselling (HTC) in Botswana
HIV testing remains low across Botswana, increasing slightly from 61.7% in 2008, but remaining under 70% in 2012.3
The government and external funders have supported voluntary testing services (VCT) since 2000, establishing over 650,000 VCT centres. The centres provide immediate, confidential VCT services for sexually active people in Botswana aged 18-49.3
Botswana recently took part in a Guinness World record 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 over three countries, 4,367 people were tested over an eight-hour period.3 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.” 8
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 to increase 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 checkups 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.9
A bill was passed in April 2013 by the parliament of Botswana, which has altered HIV testing in Botswana, allowing for mandatory HIV testing. This bill will enable directors or authorised personnel to force someone to take an HIV test and disclose their status if requested. The new bill has been contested by many civil society and human rights organisations, arguing the new bill is a step backwards for Botswana and could contribute towards increased HIV stigma and discrimination within the country.10
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.3
HIV prevention in Botswana
Whilst Botswana has shown significant progress in areas concerning HIV treatment and care, specific areas within HIV prevention have not been as effective. Comprehensive HIV knowledge and condom use remains low across the country 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. Botswana is struggling to challenge the myths and views surrounding HIV prevention and transmission, with cultural beliefs in many areas of the country pervasive.3
The understanding of HIV and AIDS by the community is critical to inform 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 a lot of the national HIV prevention programmes which are based around biomedical terms.7
HIV prevention programmes
The first national HIV programme in Botswana was in 1988 and since then different strategies have evolved. One of the most famous and successful programmes was the teacher-capacity building programme which was launched in 2004 by the Ministry of Health and United Nations Development Programme(UNDP). The programme aimed to improve the teachers’ knowledge to demystify and reduce stigma surrounding HIV and AIDS. As part of the project, all primary and secondary schools were equipped with a television, video recorder and other resources, and an interactive AIDS education programme called Talk Back was aired twice a week by Botswana television. 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.11
Botswana has utlised mass media, particularly television and radio widely for HIV prevention interventions. Makgabaneng, a very popular, long-running radio serial drama is one example of this. The series addresses a range of themes that are related to the HIV and AIDS epidemic within Botswana, such as faithfulness, cultural traditions, HIV treatment and services available. Makgabaneng has evolved beyond just radio programmes and additionally provides HIV services and information at road shows and health fairs, reaching over 20,000 people through these programmes in 2013.3
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. 2013 estimates report that 11,000 pregnant women are living with HIV and 10,648 of those women are receiving antiretroviral treatment, which is greater than 95% antiretroviral treatment coverage. The percentage of HIV-positive women who are delivering has reduced since 2009, from 13,000 to 11,000 and new child infections have dropped to below 500.1
The PMTCT programme first publically provided antiretroviral drugs in 1999 and currently operates in 634 healthcare facilities around the country. The programme has been successfully implemented and has continued to develop, launching one of the world’s first triple antiretroviral prophylaxis programmes. The success of Botswana’s PMTCT programme has resulted in a very low the mother to child transmission rate of 2.49%.3
Voluntary medical male circumcision VMMC
Voluntary medical male circumcision (VMMC) in Botswana is slowly developing, with increasing numbers of males aged 15-49 being circumcised from 11% in 2008 to just over a quarter of males being circumcised in 2013. Male circumcision prevention strategies in Botswana are struggling to effectively engage young males, with older men more likely to opt for medical circumcision.3
Antiretroviral treatment (ART) in Botswana
Masa treatment programme
The Masa antiretroviral treatment programme was launched in 2002 in Botswana. 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.12
It was estimated that in 2013, around 213,953 adults living with HIV were receiving antiretroviral therapy, equating to 69% coverage. There has been increased coverage for children too, at 84%.12
Botswana’s national treatment programme has been highly effective, especially providing treatment for pregnant women. However the challenge for the future will be sustaining the Masa programme with dramatically reduced external funding for the programme. Cost-efficiency will need to be ensured if the programme is to reach even more people and sustain its successes.1
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 the HIV epidemic is funding. 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. PEPFAR funding decreased by 30 million US$ between 2009-2012, as well as withdrawal of funding from the Gates Foundation in 2013. Financial support from CDC and ACHAR for safe male circumcision was also withdrawn.3 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.
Gender inequality in Botswana is a major barrier to HIV prevention efforts in the country. Despite new HIV infections declining among women between 15-49 years old from 5,900 in 2009, to 4,500 in 2013, a number of factors remain that increase women’s vulnerability to HIV.1 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, no policies were developed to protect sex workers and MSM. HIV prevention programmes working with these key affected populations face many barriers that increase stigma and discrimination towards these populations.
One study of female sex workers in Botswana found that many people don’t help FSW for fear of breaking the law, isolating these groups further.13 Targeted interventions that support these groups are crucial.
The way forward
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.
Despite the significant progress in HIV treatment coverage for pregnant women and children, increasing the coverage for other members of the population including key affected populations is critical.
Additionally, increasing HIV knowledge and understanding, particularly among young people in Botswana is vital to ensure a reduction in future HIV incidence.
Previous success from HIV testing campaigns has enabled Botswana to increase awareness of the importance of testing and this will be crucial for the future to enable the country to increase the numbers of people getting tested for HIV.