The heavy cost of maintaining the 95-95-95

Mbongeni Mguni - Nnasaretha Kgamanyane | Tuesday October 10, 2023 10:13

As admirable as attaining the 95-95-95 targets is, the UNAIDS’ objectives comes at a cost.

Announced nearly a decade ago as a way of ending the AIDS epidemic by 2030, UNAIDS set the 95-95-95 targets with the aim that by 2025, 95% of all people living with HIV would know their status, 95% of those who were diagnosed would be on antiretroviral therapy (ARVs), and 95% of those who were on ARVs would have viral load suppression.

Botswana is one out of just three countries that have reached the 95-95-95 targets, after Eswatini and before Zimbabwe, but experts warn that the maintaining the globally coveted status takes concerted effort and cost.

The country’s challenges are two-fold and related: one is the cost of caring for HIV in an era where budget revenues are increasingly under pressure from diminishing sources of revenues. The other is stubbornly high HIV infection rates, which mean a perpetually rising burden of disease placed on the same narrowing budget.

Figures shared exclusively with Mmegi indicate that government is spending just over P1 billion a year on the HIV effort, a considerable portion of the overall expenditure on broader public health. In fact, government has carried this load since the first case of HIV was confirmed in Selebi Phikwe in 1985, but the weight has been getting heavier over the years.

Available figures, as sourced from the last National AIDS Spending Assessment, show that government spent P865.9 million in the 2019-2020 financial year on on HIV care and treatment. The cost includes ARVs and laboratory testing, reagents and commodities, which all take up the majority of the expenditure. In the prior year, 2018-2019, government had spent P664 million.

The overall cost to government around HIV reached P1.07 billion in the 2019-2020 financial year, up from P880.1 million. For 2019-2020, the spending on HIV was nearly P412 million above the development budget funds authorised for the Ministry of Health.

Particularly concerning to those tracking public health expenditure is that the funds going towards HIV care, come at a time when new, emerging threats, such as Non-Communicable Diseases (NCDs) and long COVID are gripping the nation.

“NCDs, particularly cardiovascular disease, cancers, diabetes and chronic respiratory disease, are rising at an unprecedented rate in Botswana,” reads the Transitional National Development Plan, the overarching spending template for the next two financial years.

“They account for 46% of deaths, the same proportion of deaths as communicable, maternal, perinatal and nutritional conditions combined.

“Programme data show that over 1,400 cancers are diagnosed yearly, with the majority being diagnosed late when there is little chance of cure and treatment, which is more expensive and toxic to the patients.”

However, besides the cost, the main threat on the cost and sustainability of the country’s HIV programmes, is the stubborn rate of infection, which continues at more than 2,000 cases per annum.

“If infection rates are not reduced, yes, the cost of providing the support and to maintain the 95-95-95 situation will be threatened,” Health Ministry spokesperson, Christopher Nyanga told Mmegi.

“New infections are the drivers of the epidemic.

“So, the more the new infections the more the cost to government and other stakeholders.

“The successful ARV program keeps people alive but at a cost.

“For the epidemic to be tamed, new infections should be below AIDS deaths (epidemiological control).”

Nyanga explained that the threat to the 95-95-95 threshold is mainly due to the fact that newly infected people may be undiagnosed for a long time as the period from initial HIV infection known as sero-conversion to AIDS, referred to as symptomatic disease, may vary from five years to ten years depending on the health status of the individual.

“These individuals not knowing their status may continue to spread HIV as they are not on ARVs or not suppressed, and not using protection condoms,” he said.

Linked to the stubborn infection rates are their numerous persistent drivers, behaviours and mindsets that have resisted all manner of educational campaigns, coercions and threats over the years.

The latest BAIS, the country’s most authoritative study on HIV trends, shows how a major driver of new infections is occurring. By 2021, according to the report, it was estimated that of the 2,239 people infected every year in the country, women aged 15 to 24 years accounted for more than a third or 36%. On the other hand, in terms of prevalence, or the number of people living with HIV, adults aged between 50 and 64 accounted for nearly 27%.

Anecdotal evidence suggests that some older men taking advantage of young girls and using them sexually, a major contributor to stubborn HIV infection rates in the country. The terms “blesser” and “blessee” are convenient euphemisms to describe what HIV experts call intergenerational and often transactional sex. Experts say these terms sanitise what is in reality an unhealthy relationship where older men, who represent the second highest age group living with HIV, use their finances to woo, coerce and trap young, financially weaker and often naïve teen girls and young women.

“Intergenerational sex and transactional sex come about because of issues related to the economic vices that people face and are faced with,” Nyanga told Mmegi.

“This includes having to look for money and other things from those that have them.

“If these are provided by families and government, intergenerational sex would be less.”

He added: “The elderly men should use condoms at best (and) the young girls can use Pre-Exposure Prophylaxis (PrEP) and Post Exposure Prophylaxis (PEP).”

A detailed look into the 95-95-95s attained by Botswana underline the fact that while older men are a major contributor to the infection of young girls, at the same time, they are not carrying their fair weight of the UNAIDS target.

According to the latest BAIS, while the overall numbers are actually 95-98-98 in terms of percentages of adults aware of their HIV status, those aware and on treatment and within that, those with suppressed viral loads, adult males are actually 93-97.2-96.6. Fewer adult males their HIV status, are on ARV therapy and have achieved viral load suppression.

National AIDS & Health Promotion Agency researchers have found that men, particularly at older ages, are generally reluctant to test for HIV and tend to default on their treatment more than women.

While the latest BAIS shows commendable adherence to treatment among women living with HIV, most men exhibit elevated viral loads, primarily due to a tendency among men, unlike women, to underutilise medical services.

Surprisingly, BAIS also indicates that younger girls, or those aged between 15 and 24, have lower 95-95-95 contributions than their male peers, who test more, get on treatment more and adhere more.

The net result, going by the data, suggests that older males, with their higher viral loads, are spreading infection through intergenerational and transactional sex with young girls, who in turn at some point will want to settle down in marriage with their peers, resulting in stubborn prevalence rates.

The weight to government as well as its civic and private sector partners of providing ARVs, laboratory testing, reagents, commodities and also treating associated illnesses, will keep increasing.

“Reduction of new infections is everyone’s business.

“It is complicated and involves a combination of methods.

“It should be targeted according to the age specific groups,” Nyanga said.