Partnership for Success: CDC Helps Botswana Exceed Targets for Ending Its HIV Epidemic, 4 Years Early
In July 2022, Botswana announced results from the Fifth Botswana AIDS Impact Survey (BAIS V), which showed the country reached the UNAIDS HIV service target of 95 percent of all people living with HIV (PLHIV) to be aware of their status, 95 percent of those aware of their status will receive sustained antiretroviral treatment (ART), and 95 percent of people receiving ART will achieve viral load suppression, a reduction of HIV in the body to undetectable levels, in 2021, four years before the 2025 target date. According to BAIS V, nationally, 95 percent of PLHIV age 15 – 64 years in Botswana reported knowing their status, 98 percent of people who knew their status were receiving ART, and 98 percent of adults receiving ART achieved viral load suppression.
In December 2021, the World Health Organization also awarded Botswana “Silver Tier” status for lowering the rate of mother-to-child HIV transmission to less than five percent and providing prenatal care and ART to more than 90 percent of pregnant women living with HIV. These are two remarkable achievements for a country with one the highest HIV prevalence rates worldwide, demonstrating that ending the HIV epidemic is possible.
Enduring Partnership Leads to Epidemic Control
BAIS V is a population-based HIV impact assessment (PHIA) and the first to confirm the achievement of the ambitious UNAIDS targets for HIV epidemic control. The survey was conducted in 2021 by the University of Maryland Baltimore with funding from the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) through the U.S. Centers for Disease Control and Prevention (CDC), which also provided additional technical assistance.
Reflecting on these achievements, the CDC Botswana Country Director, Dr. Steven Hong, MD, MPH, said, “These achievements did not happen overnight, but are the products of commitment and partnerships and demonstrate the Government of Botswana’s commitment to the health of its citizens and their partnership with CDC and PEPFAR.”
In 1995, the Botswana Ministry of Health (MoH) and CDC formed BOTUSA [pronounced bah-too-sah], a partnership to strengthen tuberculosis (TB) prevention and control through public health research. The partnership expanded beyond TB in 2000 to include HIV prevention, care, treatment, and strategic information services. The additional activities maximized the quality, coverage, and impact of Botswana’s national response to the HIV epidemic. Two years later, Botswana became the first country in Africa to establish a national HIV treatment program, “Masa,” meaning “a new dawn” In Setswana. The launch of PEPFAR in 2003 expanded HIV programming, with all U.S. government agencies collaborating with the MoH toward achieving HIV epidemic control. In 2016, Botswana’s MoH adopted a “treat all” strategy to provide ART to all PLHIV who were citizens. Three years later, Botswana expanded access to HIV treatment to all PLHIV, regardless of citizenship.
When the BOTUSA program ended in 2014/15, CDC Botswana focused on supporting HIV treatment by helping to link and retain PLHIV in high-quality treatment programs. CDC Botswana also scaled HIV prevention services, including HIV testing, pre-exposure prophylaxis (PrEP), prevention of mother-to-child transmission (PMTCT), voluntary medical male circumcision (VMMC) to help adolescent boys and men to remain HIV-free, cervical cancer detection and prevention services for women living with HIV, and laboratory testing for the diagnosis and care of PLHIV. CDC Botswana also implemented DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe), a public-private partnership offering a comprehensive set of interventions addressing factors that make girls and young women vulnerable to HIV. CDC support for strategic information activities, including BAIS V, ensured the availability of high-quality data for program monitoring and improvement.
Having achieved ambitious UNAIDS targets for HIV epidemic control, MoH focuses on sustaining this progress. This will require maintenance of high-quality HIV services for PLHIV and expanding services for key populations, adolescent girls and young women, and others who face greater risks for HIV infections. This is done through evidence-based, equitable, person-centered HIV prevention and treatment programs. Programs can achieve sustained impact by supporting enduring capabilities, such as resilient and empowered country health systems and healthy communities and fostering enabling environments for increasing expertise among local partners.
To sustain the impact of its contributions, CDC Botswana is increasing technical assistance and health system strengthening across programs. This focus on technical assistance and health system strengthening will enable the MoH to continue to provide services to all the people of Botswana, leaving no one behind, and sustain HIV achievements long into the future. Technical assistance includes establishing a Clinical Mentorship Program to enhance staff capacity in MoH health facilities. The Clinical Mentorship Program supports the provision of high-quality HIV services across the HIV care continuum at the facility level. Expanding continuous quality improvement (CQI) for targeted interventions will assist with continuity in treatment and provision of person-centered care. CQI is part of routine programming and is being integrated into the Clinical Mentorship Program. This will ensure accurate data are available at the facility level, with the capacity to interpret the data, supporting HIV programs. Clinical Mentorship Program and CQI have been implemented in all 27 health districts to support staff in MoH facilities.
Data-Driven Partnerships and Interventions
CDC Botswana also supports the implementation of recency testing to collect essential information about new HIV diagnoses. Recent infection surveillance provides data on new infections, helping to tailor HIV testing strategies and target effective treatment and prevention interventions, including PrEP. Recency testing is being expanded from 10 sites to over 200 MoH sites. Recency data will be used to identify clusters of recent infections and geographic areas with ongoing transmission and activate Public Health Rapid Response Teams (RRTs). RRTs will conduct cluster investigations, review existing data to verify trends, and confirm epidemiological links. MoH and CDC Botswana have reinstituted the Field Epidemiology Training Program to develop Botswana’s public health workforce capacity. The Botswana Public Health Institute is being initiated by MoH, with technical assistance from CDC, to provide a framework for coordination and support for science-based leadership and expertise for sustained HIV response and to improve other public health activities.
Sustained technical assistance from CDC Botswana support two essential core competencies: strategic information and laboratory systems strengthening. Support for strengthened MoH data systems will enhance data completeness and quality, improve surveillance systems, and increase data use. To ensure the availability and use of high-quality data, CDC is working with the MoH to improve electronic medical records, strengthen local capacity for data analysis, leverage BAIS V results, and collaborate with other partners, such as The Global Fund, to ensure coordinated data technical assistance. Data systems strengthening activities have a national reach and contribute to program sustainability. It also supports clinical mentorship, CQI, rapid response, and other MoH program activities at the site, district, and national levels. Technical assistance for laboratory support includes quality diagnostics, emerging infection response capacity development, and help with certifying/accrediting testing and laboratory sites according to international standards.
MoH, CDC, and other partners are working together to achieve WHO “Gold Tier” certification, maintaining mother-to-child transmission rates of less than 5 percent, and increasing the provision of prenatal care and ART to over 95 percent of pregnant women – who are HIV positive – through clinical mentorship and CQI, raising the standard of care for all women living with HIV in Botswana. This will protect Botswana’s youngest and ensure the next generation is born free from HIV.
The partnership between MoH and CDC Botswana is dynamic and responsive to the trajectory of Botswana’s HIV epidemic. Having reached HIV epidemic control, deeper cooperation is essential to sustain impact. With support from PEPFAR, CDC Botswana will continue to support Botswana’s HIV treatment programs and prevention services for sustainable HIV impact.