Botswana Leads in HIV Treatment

From left: Lyorlumun Uhaa, UNICEF; Michel Sidibé, UNAIDS; Max Essex, Harvard AIDS Initiative; Pride Chigwedere, UNAIDS, at a meeting for African Leaders in Addis Ababa. Photo by Aida Muluneh

Billions of dollars are spent every year on HIV/AIDS treatment programs. But how well are they working?

In the African country of Botswana, where 25% of adults (aged 16-49) are HIV positive, the answer is extremely well. In a recent paper in The Lancet HIV, researchers showed that Botswana is close to reaching the ambitious UNAIDS 90-90-90 goals.

In 2014, UNAIDS proposed new testing and treatment targets directed towards ending the AIDS epidemic: by the year 2020, 90% of all HIV-infected people would know their HIV status; 90% of those diagnosed with HIV would be on antiretroviral therapy (ART); and 90% of those on ART would have a suppressed viral load (very low levels of HIV in their blood). A growing body of research shows that providing ART to people living with HIV, besides being good for their own health, lessens their chance of transmitting HIV to others.

Researchers Surprised

The data for the paper was taken from the Botswana Combination Prevention Project (BCPP), an on-going clinical trial designed to measure how well a package of HIV prevention measures reduces the rate of new infections. Researchers at the Harvard AIDS Initiative (HAI) and their colleagues at the Botswana Harvard AIDS Institute Partnership (BHP) are responsible for the design and evaluation of the project.

Adults aged 16 to 64 were recruited from a random sample of 20% of households in each of 30 Botswana villages.Participants answered questionnaires and were tested for HIV. The data collected from the BCPP is among the most complete population-level estimates of HIV available for southern Africa, the epicenter of the AIDS epidemic.

Of the 12,610 participants surveyed, 3596 (29%) were infected with HIV. Of those individuals, 2995 (83%) already knew their HIV status. Among those who knew their status, 2617 (87%) were receiving ART. Of the 2609 individuals receiving ART who had a verifiable viral load test, 2517 (96%) had a suppressed HIV viral load.

For a national HIV treatment program to achieve viral suppression in 96% of patients on ARVs is considered exceptional. The high rate was a surprise, even to the researchers. “I thought it would be very good, by which I would have said 90% or so. I was surprised that it was as high as 96%,” said Max Essex, Senior Principal Investigator of the BCPP and Chair of both HAI and BHP.

Why Botswana?

According to a recent analysis of HIV treatment programs, no country has yet met the overall UNAIDS goals. Very few countries, including the U.S., have come close to Botswana’s coverage.

Why has a middle-income African nation with a high HIV prevalence been able to create a more successful HIV treatment program than richer Western countries?

“Remember that the set-up of the Botswana national health system is that 95% of all people are within five-kilometer access of a healthcare facility,” said Dr. Tendani Gaolathe, BCPP Project Director and first author on The Lancet HIV paper.

“In Botswana, there’s been dedicated governmental action at the highest level to take responsibility for the epidemic. Healthcare, including antiretroviral treatment, is free for all citizens in the country,” said Essex. “The government has also sought international cooperation with us and others to get the latest advice and the best understanding of what can be done.”

Attainable & Meaningful

When the UNAIDS 90-90-90 targets were first announced, many in the international community questioned whether they were achievable, especially by 2020 in resource-strapped countries with a high burden of HIV. The findings from Botswana indicate that the targets are attainable.

“This is significant work as it provides further evidence that UNAIDS 90-90-90 treatment targets are both realistic and achievable,” said UNAIDS Executive Director Michel Sidibé.

“The targets are definitely more than bureaucratic goal posts,” said Essex. “It’s clear that rates of new infections will go down dramatically as a result of reaching these goals.”

The BCPP is funded by the President’s Emergency Plan for AIDS Relief (PEPFAR), through the Centers for Disease Control and Prevention.

Title Photo by Aida Muluneh. From left: Lyorlumun Uhaa, UNICEF; Michel Sidibé, UNAIDS; Max Essex, Harvard AIDS Initiative; Pride Chigwedere, UNAIDS, at a meeting for African Leaders in Addis Ababa.