The In Danger: UNAIDS Global AIDS Update 2022 shows that over the last two years, crises have created extraordinary headwinds that threaten national AIDS responses in Botswana and beyond.
Amid these challenges, Botswana was the first high-burden country to achieve silver status on the path to the elimination of vertical HIV transmission.
The Silver Tier requires an HIV case rate of fewer than 500 per 100,000 live births, a vertical HIV transmission rate of under five percent and the provision of antenatal care and antiretroviral treatment to more than 90% of pregnant women.
“Over 95% of pregnant women in Botswana were receiving antiretroviral therapy in 2021, up from 77% in 2010. Vertical transmission rates were only 2.2%, down from 9.0% a decade earlier,” says the In Danger report.
Botswana applied to be validated on the Path to Elimination (PTE). The application was based on the successful preliminary review of process and impact indicators for the years 2017-2019.
The products of the process included the Botswana EMTCT National Validation Report (NVR) and the Afro Regional Validation Report (RVR). These documents provided the WHO Global Validation Advisory Committee (GVAC) with a strong recommendation to certify Botswana as having met the impact and process indicators for the Silver Tier of PTE during the two-year review period 2018-2019.
Substantial progress has been made overall in reducing new HIV infections as the number of new infections nationally has declined by 46% from 2010 to 2021 (30% among adult females and 60% among adult males).
The silver status certification is an important milestone for Botswana, as well as for other high-burden countries. It tells the important story, that an AIDS-free generation is possible. It is also illustrative of what can be achieved through a collaborative effort between a visionary political leadership in partnership and a society committed to the advancement of public health priorities.
Despite this progress, the reduction in new HIV infections has been slow. Progress needs to be accelerated if we are to end AIDS as a public health threat by 2030. Botswana’s national achievements tend to obscure the slower progress in preventing new infections among adolescent young girls and women, and key populations that include gay men and men who have sex with other men, LGBTQI persons and sex workers. Key populations have a relatively higher risk of acquiring HIV.
The 2017 Behavioural And Biological Surveillance Survey of Botswana shows female sex workers have an HIV prevalence of 42.8% and HIV incidence of 2.9% which is 2.6 times higher than the incidence among adult women. UNAIDS commends Botswana for the historic decision where Botswana decriminalised same-sex sexual relations in a court of appeal, November 2021.
However, laws that criminalise sex work still remain and undermine efforts to reach and link sex workers to national HIV response programmes. Data show that Botswana has 360,000 [340,000-390,000] adults and children living with HIV. Women and girls are also disproportionately affected by HIV, accounting for 71% of new HIV in 2021.
New infections are three times higher among adolescent girls and young women (15-24years) than among men the same age. With this said, it is important to close the tap of new infections by effectively scaling up evidence-informed high-impact programmes for key populations and adolescent girls and young women. Age of consent for HIV testing and sexual reproductive health rights (SRHR) services, lack of access to youth-friendly services, lack of condoms in schools and quality comprehensive sexuality education are all impeding efforts to fully access HIV services.
The implementation and scaling up of the five-year (2019-2023) National Programming Framework for Adolescents and Young People (AYP) and Key Populations will be key to bridging this gap. UNAIDS calls for an increase in domestic funding for health and HIV funding.
The human and financial cost of not ending AIDS by 2030 would far outweigh the cost of the immediate and necessary action to turn the ship around. Urgent action and international solidarity are needed to build systems resilience for such shocks in future and focus on the sustainability of the AIDS response. A sustained AIDS response in Botswana will require tapping into efficiency gains and doing more with less. Communities have an essential role in leading localised responses to HIV.
Concerted collaboration among government, civil society and communities must be integrated into national and provincial planning, implementation and monitoring. Communities need adequate resources and to have legal barriers removed where they impede community-led responses. Botswana must earnestly ring-fence and sustain the gains made in the AIDS response. Ending AIDS is a promise that can and must be kept.
ALANKAR MALVIYA is the UNAIDS Botswana Country Director
